Overcoming Crystal Meth Addiction

^Petros levounis, MD, MA, Director,
The Addiction Institute of New York

and Chair, Addiction Treatment Committee,
American Psychiatric Association
ADDICTION
An Essential Guide
to Getting Clean
STEVEN J. LEE, MD
Boston Public Library
Boston. MA 02116
PRAISE FOR OVERCOMING CRYSTAL METH ADDICTION
"Dr. Lee has managed the impossible: taking one of the most scientifically,
clinically, and socially challenging conundrums of the twenty-first century
and turning it into a great hook that provides real down-to-earth help for all
crystal methamphetamine users and their families."
— Petros Levounis, MD, MA, Director, The Addiction Institute of New

York; Chair, Addiction Treatment Committee, American Psychiatric
Association; Co-Chair, Public Policy Committee, American Society of
Addiction Medicine
"Finally! An unbiased, comprehensive, understandable book about crystal.

Dr. Lee gives the facts and offers attainable solutions to the pandemic."
— Kat Coric, BFA, artist, AIDS activist
"In Overcoming Crystal Meth Addiction, Steven Lee performs a great service
by normalizing methamphetamine dependency. It turns out that this addic-

tion, which has been sensationalized in the media, responds to the same mix
of therapy, self-reflection, and twelve-step work as every other addiction.
Lee's recipe spells hope for recovery."
— Patrick Moore, author of Tweaked: A Crystal Meth Memoir

and "The Principles on Yahoo! Health
'
"Overcoming Crystal Meth Addiction is a well written review of the history

of this menacing epidemic and its devastating impact on victims and their
families. In text easily understood by the consumer. Dr. Lee clearly explains
the principles underpinning meth and addiction before transitioning to very
helpful information about overcoming meth and staying clean. His five strat-
egies for beating meth addiction and a useful glossary
are clearly outlined
of scientific and street terms as well as information on harm reduction and
treatment resources are also included. Dr. Lee has invested substantial effort
in writing this complete and understandable book that will appeal to a wide
audience. The result is a valuable resource that bridges the gap between the
consumer and the science of meth addiction."
— Scott Letendre, MD, Associate Professor of Medicine, HIV
Neurobehavioral Research Center and Antiviral Research Center,
University of California, San Diego
"This is the most comprehensive book on crystal meth I've seen. It answers
all of the commonly asked questions: what is crystalmeth? how is it made?
how long has it been around? how is it used? why is it so popular? what works
in treatment? and how do people stay sober? For the person using crystal
meth or contemplating using meth, it provides the most readable information
regarding what it does to the body, the dangers of use and abuse, exercises
for determining use and quitting, and resources for getting help. I highly
recommend this book and plan on providing copies for all the clinical staff
at all of our facilities at Alternatives, Inc."
—Joseph M. Amico, MDiv, CAS, LISAC, President, National Association

of Lesbian and Gay Addiction Professionals (NALGAP); Vice President for
Program Development and Community Educator, Alternatives Inc.
"Finally, a book that has a dual approach: stressing the danger of the drug
and its addictive nature and engaging everyone — people in recovery, users,
and mental health professionals — into a more contextual exploration of the

complex factors that lead someone to fill up his or her life's 'holes' with crys-
tal meth. Timely, informative and nonjudgmental. Dr. Lee's book offers an
essential tool to examine the role of stress, depression, and unhappiness in
one's decision to use crystal meth. It pays respectful attention to the cul-
ture of crystal use in the gay community and offers thoughts applicable to
other communities affected by crystal. By describing 'the good, the bad, the
glamorous, and the ugly' aspects of crystal meth use, Lee not only provides
concrete strategies to stop using but also invites us to take a deeper look at
the underlying causes of crystal meth addiction. This book is an invitation to

"
a richer and fuller life, without addiction
—Jean Malpas, MA, LMHC, LMFT, psychotherapist

STEVEN J. LEE, MD
OVERCOMING
CRYSTAL METH
ADDICTION
An Essential Guide
to Getting Clean
Marlowe 8c Company • New York

Overcoming Crystal Meth Addiction:
An Essential Guide to Getting Clean
Copyright © 2006 by Steven Lee J.
Preface copyright © 2006 by Marc Galanter

Published by
Marlowe & Company
An Imprint of Avalon Publishing Group, Incorporated
245 West 17th Street • 1 1th Floor
New York, NY 1001 1-5300
AV A L 0 M
All rights reserved. No part of this book may be reproduced in whole or in part
without written permission from the publisher, except by reviewers who may quote brief
excerpts in connection with a review in a newspaper, magazine, or electronic publication;
nor may any part of this book be reproduced, stored in a retrieval system, or transmitted
in any form or by any means electronic, mechanical, photocopying, recording, or other,

without written permission from the publisher.
The information in this book is intended to help readers make informed decisions about
their health and the health of their loved ones. It is not intended to be a substitute
for treatment by or the advice and care of a professional health care provider. While
the author and publisher have endeavored to ensure that the information presented is
accurate and up to date, they are not responsible for adverse effects or consequences sus-
tained by any person using this book.
Library of Congress Cataloging-in-Publication Data
Lee, Steven J.
Overcoming crystal meth addiction an : essential guide to getting clean from

CM addiction / Steven J. Lee ;
preface by Marc Galanter.
p. cm.
Includes bibliographical references and index.
ISBN 1-56924-313-1 (pbk.)
1. Methamphetamine abuse-Prevention. 2. Drug abuse-Patients-Treatment. I. Title.
RC568.A45L44 2006
616.86'406-dc22
2006018149
f
ISBN-13: 978-1-56924-313-8
9 8 7 6 5 4 3 2
Designed hy Pauline Neuwirth, Neuwirth Associates, Inc.
Printed in the United States of America

For Ron, who taught me that imperfection is the most
beautiful thing about being human

Digitized by the Internet Arcliive
in 2015
littps://archive.org/details/overcomingcrystaOOIees
CONTENTS
Preface by Marc Galanter, MD xi
Introduction 1
PART 1: Understanding Crystal Methamphetamine:

Getting to Know Tina Up Close and Personal 13
1: Blue Meth, Super Ice, Crank, Tina, Chicken Feed: 15

A Short History of Crystal Methamphetamine
2: What Exactly Is Crystal Methamphetamine? 28
3: How Is Crystal Made? 40
PART 2: Understanding Addiction:

What Is It and Do You Have It? 43
4; Medical Disease or Weak Personality? What Is Addiction? 45
5: What Is All the Hype about Crystal? 49

Is It Really More Addictive Than Other Drugs?
j- Do You Think You May Be Addicted? 55
7: Taking a Look at Crystal in Your Life: 64

Is Tina Just an Occasional Visitor or Has She
Become the Houseguest Who Just Won't Leave?
PART 3: How Can You Handle Crystal in Your Life? 85
I: What If You Use Crystal and You Don't Want to Stop? 87

viii I CONTENTS
Stopping Crystal— When You Feel That You Have

Lost Control of Your Life and You Want It Back
PART in Now That You Have Stopped Using,

How Do You Stay Clean?
lU: Relapse Prevention: Working on Staying Clean
11: Things You Can Do to Beat Crystal Addiction:

Some Specific Strategies
PART 5: Other Important Areas in Your Life That Can

Keep You Clean and Sober
12: Self-Esteem: How Much Do You Really Like Yourself?
13: Social Anxiety: When It's Difficult to Feel Comfortable

Around Other People
14: Depression: When Nothing Feels Good-

Is This the Way Life Is Supposed to Feel?
IS: Work: When You Need to Keep Your Job Performance

and Productivity High
IJ: Attention-Deficit/Hyperactivity Disorder: You're Not

Lazy or Depressed, So Why Do You Still Have Trouble
Getting Things Done?
l7: Life Is a Balancing Act: Stress Management
11: Who Is in Your Social Circle? Dealing with Loneliness
and Finding a Sober Group of Friends
1 j: Crystal and Sex: If Sex on Crystal Is So Amazing,

Is It Possible to Enjoy Sex Without It?
PART 6: Special Topics
ZJ: What If You Slip? Does It Mean Failure?
21: You Are Who

You Are, and That's Okay: Acceptance—
the Cornerstone of Staying Clean
22: Crystal and HIV: How Do They Affect Each Other?
23: What Do You Do If Someone You Know Has a Problem

with Crystal?
21
CONTENTS I ix
APPENDIX 1 : Abstinence-Based Treatment and General 29

Information Resources
'
APPENDIX 2: Harm-Reduction Resources 295
Glossary 297
References and Bibliography 3 1
Acknowledgments 327
Index 329
PREFACE
hy Marc Galanter, MD
The magnitude of the alcohol and drug abuse problem in the United
States is well documented. Eighteen percent of the population experi-
ences a substance abuse disorder at some point in their lives, and the cost
of addictive illness to the public has been calculated to be $246 billion
annually in health care and lost work. Furthermore, at least 20 percent of

patients in general medical facilities and many more in general psychiatric
units have addiction problems, many of which go undiagnosed. Despite

much progress in recent years, the addicted person still bears the burden
of being stigmatized. When the secondary effects of addiction, such as
cirrhosis, psychopathology, trauma, and infection are present, they may
receive proper medical attention; patients' primary addictive problems,
however, often go untreated.
Fortunately, important advances are being made in the addiction field.
Basic research involving receptors, membrane chemistry, and genetic trans-

mission has been elaborated. Public awareness has been aroused so that
substance abusers seek help earlier, when treatment can be administered
more effectively. New treatment concepts, both in medication and counsel-
ing, have made recovery a possibility for the majority of alcohol- and drug-
abusing patients. Furthermore, the health community has been alerted to the
need for early diagnosis and provision of comprehensive care. But the power
of new substances to generate addictions cannot be underestimated.
Each generation seems to bring with it a new series of drug problems to
be confronted, and, increasingly, each has its roots in earlier approaches to
xii I OVERCOMING CRYSTAL METH ADDICTION
pharmacology and medical research. Cocaine was isolated from coca leaves
in 1844, and its use as a local anesthetic was introduced by the surgeon
William Halsted, who himself became addicted to the drug. Morphine
was popularized during the Civil War to allay the pain of wounded sol-
diers. When heroin was synthesized in the late nineteenth century, it was
thought to be a nonaddictive means of treating withdrawal from morphine.
Amphetamines were first synthesized around the same time, and during
World War II, their use was sanctioned by a number of governments,
Japan in particular. Defense workers and civilians used amphetamines for

their energizing qualities. In the 1950s and 1960s, the contents of inhal-
ers containing benzedrine, a drug in the amphetamine family, were being
injected intravenously. By 1970, the Controlled Substances Act led to
the removal of these nonprescription inhalers from the market. By then,

methamphetamine was already being abused.
Crystal methamphetamine has come to be a substitute for cocaine in
many parts of the country and in certain population subgroups. Within

the last decade, its abuse has inflicted great damage, particularly in the
American heartland, where it has gained considerable popularity because

of the ease withwhich it can be produced, and at a low price. It has
become popular among some members of the gay community as well.
This book provides a valuable body of information on crystal meth,
presented coherently and thoughtfully. It addresses the issue head-on by
clearly explaining how methamphetamine affects the body, by enumerat-
ing the grave problems associated with its use, and by providing options
for achieving recovery from dependence. It will be of considerable value
to anyone who needs to be acquainted with these issues, or who wants an
introduction to the interface between culture and pharmacology, and how
drugs of abuse can come to produce major public health problems.
Marc Galanter, MD
Professor of Psychiatry
Director, Division of Alcoholism and Drug Abuse
New York University Medical Center
PREFACE I xiii
Marc Galanter, MD, is Professor of Psychiatry and Founding Director of the Division of
Alcoholism and Drug Abuse at New York University (NYU) School of Medicine. He has
ser\'ed as president of several national organizations, including the American Society of
Addiction Medicine and the American Academy of Addiction Psychiatry. As the Division
Director of NYU's World Health Organization Collaborating Center and NYU's National
Center for Medical Fellowships in Alcoholism and Drug Abuse, he has guided the teaching
and training of addiction treatment at teaching hospitals and medical schools throughout
the United States. He is the author of over 250 articles, chapters, and books dealing with
addiction, addiction treatments, and spirituality.
INTRODUCTION
Justin is a twenty-two-year-old high school graduate living in rural
Missouri. He works at a gas station part time but spends most of his days
feeling bored, and frustrated that his life is going nowhere. The exciting
scenes he watches on television are a far cry from life in his quiet farm-
ing community. There is not much to do where Justin lives. The closest
town is an hour's drive away. He does not know who his father is, and he
lives with his mother, who is unemployed and spends most of her time
watching TV at home.
Justin started using crystal when his friend offered it to him one
afternoon while they were sitting on the couch channel surfing on the TV.
He felt amazing the first time he tried it because life suddenly seemed
interesting, fresh, and vibrant. Worries about not getting anywhere in life
or feeling bored disappeared, as even small things could catch his atten-
tion and seem fascinating. He stopped pitying himself and instead he felt
powerful— he saw himself as a good-looking young man with the world

at his feet, and his mind filled with possibilities. Sometimes he could
become completely engrossed in a seemingly random activity. Once, he
took apart his computer thinking he was going to fix a small problem he'd
been having: Several hits from his crystal pipe and, twelve hours later,
his computer lay in small piles of electronic pieces scattered around his
bedroom. The place was in chaos: to an outsider, his room looked crazy.
[ electronic parts strewn about in a mess that could never be put back
^ together into a working machine. Yet. while Justin kept smoking crystal,
^ it all made sense to him. and he was determined to get to the bottom of
i the computer problem.

2 I OVERCOMING CRYSTAL METH ADDICTION
r Justin would hang out with his friends at honne, and all of them would
I
smoke or snort crystal together Sometimes his mother would join them
and get high. Usually she sat with them and talked, but sometimes she
I
f
and Justin's friends started feeling extremely sexual. (Justin's mother has
had sex with most of his friends by now, but Justin denies ever having sex
-
with her) One day, he found out his mother was pregnant, carrying the
'
child of one his buddies.
Justin was upset at first, but he kept using crystalto try to make himself
feel better, and he distracted himself with other things. Gradually. Justin i
I
started believing that people were following him. Even though he was in a
j
small rural community where most people already knew each other well, i
he was sure that someone was following him. Although cars and trucks |
on the road were usually different, he was convinced it was the same
person getting into different vehicles to throw off his suspicions. When he
saw the people inside each vehicle were different, he decided there must
be a team of people conspiring to follow him, maybe because of what he l
was finding in his computer After he tacked up a sheet on his bedroom |
window to prevent people from seeing inside, he started to suspect that J
someone might have bugged his room with a tiny electronic device hidden ?
in one of the little electronic pieces strewn about his bedroom. Eventually,
Justin started to hear voices that confirmed his suspicions. He was right!
But the voices were scaring him, telling him frightening things about what
other people wanted to do to him. He became withdrawn and rarely left J
his home, too scared and paranoid to go to work. Eventually he lost his
j
job and he stayed at home with his mother, collecting welfare and using |
, It to support his crystal habit. He became a recluse, even within his own
|
S house. Before. Justin's life was centered on hanging out with his friends |
and complaining of boredom. Now his life revolves around using crystal, |
while he hides in his room, terrified. I

INTRODUCTION I
Brian is a thirty-four-year-old gay white man who works as an attorney
and has a busy professional life. He is proud of the fact that he "works
hard and plays hard." After a difficult life as a closeted gay teenager grow-
ing up in a suburb of Chicago, he left his community to go to college and

law school in the Northeast and then moved to New York City, where he
discovered the gay party scene. Brian found gay discos and circuit par-
ties liberating; they were places where he could be open about his sexual
orientation and bond with other gay men. After joining a gym and doing a
few cycles of anabolic steroids, he looked in the mirror and saw an attrac-
tive person, unlike the awkward and embarrassed teenager he used to
be. who had hidden his sexual orientation from his friends because the
homophobia in his school had made him feel so ashamed. In New York
City, he joined a circle of friends who went to discos and circuit parties,
where drugs such as Ecstasy, special K, cocaine, and crystal were the
norm. He considered himself a member of the "A list." a group of the most
attractive and successful gay men in New York City. Now, he thought, he
was someone that everyone else wanted to be. This felt so much better
than having to live a lie to avoid not being accepted by his peers. Now,
rather than be looked down on as a loser because he was gay. it was his
turn to feel better than others and to look down on them.

At first, Brian preferred Ecstasy when he went out, but occasionally
he would do a bump of crystal if someone had any, maybe two or three
times a year. Gradually his use increased to a couple of bumps every
month. About five years ago. when crystal was becoming more popular in
New York, he saw others doing it more often, and he started using more
himself, almost every weekend. He discovered that crystal made him feel
great and even more confident. He became horny when he used crystal,
and his main objective at discos was to hook up. Sex on crystal was amaz-
ing, and for the first time in his life, he didn't have any hang-ups about
being gay or fearing HIV. He just enjoyed the sheer pleasure of sex.
Brian began using the Internet to find hookups, and gradually he
stopped going out to the discos because he saved time just getting
crystal from his dealer and going online to find sex. An indulgence that
started out as one night of sexual pleasure quickly grew to staying up for
two to three days at a time. Instead of snorting bumps, which had actu-
ally become lines, he started smoking and even occasionally slamming

OVERCOMING CRYSTAL METH ADDICTION
(injecting) crystal. He would crash and feel terrible on Mondays, eventually

starting to call in sick. "Sick Mondays" became nnore frequent, and Brian's
work performance suffered. He was given a warning by one of the law firm's
partners. His prospects for becoming a partner of the firm were not looking
good. He was not even sure if he would be able to keep his job.
Meanwhile, on the weekends. Brian continued his crystal-sex binges,

sometimes using the Internet, sometimes going to sex clubs orsex parties
hosted by his dealer. He'd often have sex without condoms. Sometimes
he would start with a condom, but he would find it annoying, getting in
the way of the wild frenzy of intense sex, and he would rip the condom off.
When he was high and having sex. the only thing he wanted was more sex
and more crystal, even if he wasn't able to get an erection. Sometimes

Brian would wake up the next day with a very sore or slightly bloody anus
from two days of continuous anal sex. or he would have painful abrasions
on his penis. One day. Brian went to his regular medical check-up. and
he was tested for everything. When his blood tests came back later that
week, he found he was HIV-positive.
All€l is a seventeen-year-old Mexican-American teenager, growing up
in a small suburban town outside San Diego. She was born in Southern
California, the third of four children of parents who had emigrated from
Mexico thirty years earlier Her parents each worked two jobs, hoping that
their children would get good educations and be able to have better lives.
However, her mother and father were both busy working, and no longer
being the baby of the family. Ana felt neglected by them, despite their best
intentions. Ana was just a regular teenager who wanted to fit in. She went
to school regularly and did fairly well in her classes.
Though there were many Mexican Americans in Southern California,
there was a strong social pressure that "blond + thin = attractive." Social
pressure was so strong that many Mexican-American high school stu-
dents used to bleach their hair, even though the result looked unnatural.
Ana was never interested in being blond, and she had always considered
her thick black hair to be one of her best features. However, she became
concerned about her tendency to put on weight and did everything she
could to lose it. She found out from a classmate that if she snorted small
INTRODUCTION I 5
amounts of crystal, she would lose all desire to eat. Also, on crystal, she
felt so much better about herself that her weight almost didn't even mat-
ter As an extra benefit. Ana found that crystal made her more alert in
class, and she could get her work done much more easily. When she had
a test or paper, she could easily stay up all night on crystal and pass the
test the next day.
Meth felt like the perfect solution to Ana's concerns, and it was rela- I
tively cheap. Just doing occasional bumps, she would pay $40 for a little
bag. which would last her a couple of months. However, the occasional
small bump gradually turned into a daily habit because, on days that
she did not use crystal. Ana became tired, depressed, and hungry. On
those days, she also felt even worse about her appearance: looking in
the mirror was painful. Over time Ana lost a significant amount of weight.
Her plan worked too well— she was now not only thin but malnourished.
Regardless, on the days Ana used crystal, she felt great and saw an
attractive person in the mirror, and when people stared at her gaunt face
and sickly body, she knew that they were really looking at her because she
had become so attractive, and that they were jealous.

As Ana started to use more crystal, it became expensive to support her
habit, and she began stealing. She didn't want to steal, but the trade-off
was too expensive— looking and feeling terrible, and falling into depres-
sion. Ana was caught shoplifting and was arrested. The court mandated
her to start a residential treatment program for drug addiction.
Justin, Brian, and Ana are case examples of three very different people
struggling with distinct issues of crystal addiction. We will revisit them
throughout the book to see how they coped (or were unable to cope) with
the issues I discuss in the various chapters.
Crystal methamphetamine is an extremely powerful drug. It crosses
social, cultural, and economic lines because it can cause such positive
feelings in so many different ways. However, it can also have devastating
effects on every aspect of a person's life. Crystal is an old drug that has
been with us for almost a century. There have been several waves of epi-
demics of methamphetamine (meth) use around the globe, so addiction
to it is nothing new. And now, worldwide, it is experiencing a new wave.
However, this current epidemic is worse than others because social cir-
cumstances in the world have changed: natural barriers that would have
kept it more contained no longer exist, and other illnesses, such as HIV
and hepatitis, make it more of a deadly, raging force.
In the information and technology era, ingredients to make metham-

phetamine are easily available on the Internet, so the drug is easier than
ever to produce and to procure. As HIV continues to spread across the
globe, a drug that causes intense sexual cravings and makes people ignore
safer-sex practices continues to fuel the HIV epidemic, as well as the
spread of other sexually transmitted diseases such as hepatitis B and C,
which can all be deadly. The irregular and intermittent use of HIV medica-
tions by someone getting high frequently can breed strains of HIV that are
resistant to the medications that are currently available, while researchers
are spending billions of dollars trying to create new drugs to keep up with
the changing virus. "Virus swapping" by people having unprotected sex
and exchanging different strains of HIV make the situation even more
complicated.
The Internet and the explosion of gay sex hookup sites in the late
1990s and early millennium made the possibility of finding sex while
high on crystal as easy as ordering in dinner. In previous decades, people
felt oversexed on methamphetamine; with the Internet, the possibility of
sexual activity became almost limitless. The reinforcing effects of having
sex readily available then fuels addictive use of methamphetamine even
more.
The U.S. Department of Health and Human Services reported that in
2002, over 12 million people over the age of twelve reported having tried
methamphetamin. Of those surveyed, almost 600,000 were current users.
With a growth rate of about 300,000 new users per year, those numbers
are much higher now.
The people who use crystal methamphetamine are found in all socio-
economic and ethnic groups:
M The working class in Hawaii, where this current epidemic is
thought to have started, has been devastated by methamphet-

amine use: there, it is a drug that helps the plight of the weary,
giving them energy to be able to hold the two or more jobs that
many take on to survive the high cost of living in Hawaii.
.
INTRODUCTION I 7
Unlike other illegal drugs, crystal has been reported to cross
generational lines, with whole families using crystal together.

In rural areas of the continental United States, one of the key
ingredients for methamphetamine production, which is used as
a fertilizer, is easily available in large quantities, and the open
space makes it easy to build clandestine production labs. For this
reason, the rural Southwest and Midwest have been particularly
hard hit.
Among teens, in 1999, 4.7 percent of American high school

seniors reported using meth.
In major metropolitan areas, many gay men use methamphetamine,
and it has become the drug of choice in gay clubs and circuit par-
ties. This has significantly affected the attempts to stop the spread
of HIV in these communities. At one Los Angeles clinic in 2005,
one out of three gay or bisexual men who tested positive for HIV
admitted to using crystal. This percentage is three times greater
than what had been found in the same clinic in 200 1 Including . all
people who came to that clinic for testing, whether positive or nega-
tive for HIV, more than 10 percent admitted to using crystal —twice
as many as had been reported in 200 1
There have been reports of its use even in unexpected communi-
ties, such as among the Amish and Mormons, where strict moral
prohibitions and cultural isolation would be expected to protect
them from the spread of meth use.
Methamphetamine use is clearly growing, and its combination with

other dangerous epidemics, such as HIV and hepatitis B and C, makes it
even more frightening. It is a powerfully addictive drug.

As an addiction psychiatrist in New York City, I have witnessed metham-
phetamine spread across the city and devastate the community. Although
recent efforts by the government and community service agencies have
valiantly tried to combat this epidemic, there ismuch confusion and dis-
agreement about how to address the problem. Some people want to dra-
matically portray the most extreme effects of the drug to shake people
awake and cause some action. Others criticize this tactic as "demonizing"
the drug and alienating users who see it as enjoyable, as the opposite of
what is shown in frightening ad campaigns. Some people feel that harm
reduction —allowing people to make their own decisions and teaching them
how to use methamphetamine safely — is the best approach, whereas others
feel that harm reduction just allows more people to reach the point of severe
addiction, when it is too late to help them. The real answer Hes somewhere
in between, and this book is an attempt to find that midpoint.
I wrote this book for laypeople, to help them prevent crystal from taking
over their lives, and for those who are addicted, to help them achieve sobri-
ety. While treatment services are available —more are being developed and
refined every day —the average crystal user either is not aware of them or
does not want to use them.
It is know if you have a problem with crystal, and, even if you
difficult to
know that you do, it may be extremely difficult for you to ask for help. As
you read this book, it will become clear that recovery from meth addiction
involves reaching out to others and getting help from resources beyond this
book. But if you are not yet at that stage, or if you don't believe you are an
addict, you can also use this book to achieve a better understanding of why
you may be using crystal and what it may be doing to you. If you are an
addict, this book will show you the fundamental principles of overcoming
methamphetamine addiction, no matter what treatment option you may
choose to take.
This book is also intended for substance abuse specialists who want to
refine their understanding of methamphetamine, the experiences of meth

users, and specific treatment strategies for meth addicts.
My approach to overcoming crystal methamphetamine addiction in-
volves five fundamental strategies:
1 . Learn as much about crystal as you can. If you know what you are deal-
ing with, then you will understand why it makes you feel and be-
have the way you do. Only then can you fully judge whether you
are controlling your crystal use or vice versa. Also, if you know the
physiological actions of crystal, you can strategize better how to
fight back when it makes your brain crave more, even if rationally
you want to use less.
2. Take a close look at what role crystal plays in your life. Is it something
that you just use for fun, something that you control? Or has it
become something that has taken control of you without your even
realizing it?
INTRODUCTION I 9
3. Learn the basic steps to stop using crystal. If you are stuck in a pattern
of using and you can't get out of it, this book offers approaches
to stopping using, such as detoxing, something that many do not
realize is a possible way to ease the difficulty and pain of ending
a binge or a long cycle of crystal use.
4. Learn how to stay clean. What are the basic treatment options, in-
cluding programs, therapies, and medications? What are some
housekeeping tips for life that can lower your risk of falling back
into using crystal? Even after countless experiences of the highs
of cr^^stal, you can still enjoy life without it — the book suggests
strategies for relearning life, such as how to socialize without the
drug, and how to enjoy sober sex.
5. Make sure that you address major "holes " in your life that you may be trying
to fill with crystal: depression, loneliness, weight control, boredom, sexual
excitement, low self-esteem. Using crystal superficially covers many

gaps that need improvement, but if they are never addressed and
actually filled in, then the urge to use cr}'stal —your old reliable
coping mechanism — will kick in and make you want to use again.
This book is divided into five major sections that follow these funda-
mental areas for overcoming meth addiction. Part 6 includes special topics
that may be of interest to specific populations, such as people who have
HIV, and loved ones of crystal addicts.
Overcoming Crystal Meth Addiction is not a blanket condemnation of
crystal, and it is not an endorsement of crystal use. Like nuclear power,
methamphetamine can cause powerful reactions, with some good effects,
but it can also be extremely destructive. I attempt to provide a neutral
description of what exists in the crystal-using world. To overcome crystal

addiction, it is crucial to understand all sides to this drug —the good, the
bad, the glamorous, and the ugly. Many people who have had good experi-
ences using crystal understandably scoff at advertisements that demonize
the drug and portray it as all bad. I take the approach that there are both
good and bad aspects to crystal —people start using it regularly because
something about it indeed feels good. Acknowledging the good experi-
ences of meth is important because they exist, and a program that doesn't
recognize this wouldn't hold much credibility for you. If you have to stop
using it, there is a mourning process of saying good-bye to this intimate

but often destructive relationship. In addition, understanding the ways

crystal ''helps" you is also crucial in identifying areas in your life that may
need improvement.
Because of the extremely addictive nature of methamphetamine, I make
it clear that the safest way to avoid problems with this drug is not to use it
at all. However, many crystal users are not willing or ready to part with it.
For those people, this book also serves as a guide to a better understanding
of crystal, so you know what you put into your body; how to reduce your
medical risks if you do use crystal; and how to monitor your use over time
to assess if you are developing an addiction.
This book was written using current medical understandings of meth-
amphetamine, the brain, and addiction behavior. In addition, I have drawn
on conversations with and stories of hundreds of people struggling with
crystal addiction, learning from their experiences of what crystal has meant
to them —how it helped them with many things, but also how it has devas-
tated many lives. They have also taught me what has been helpful to them
and have shared with me their success stories, which I will try faithfully to
pass on in this book. All names of cases mentioned throughout this book
have been changed to protect people s anonymity. If you have recently
tried or are even contemplating using methamphetamine, I hope that this
compilation of broad experiences and suggestions will help you find your
way to a life and lifestyle safe from the dangers of crystal addiction.
STRATEGIES TOR OVERCOMINa CRYSTAl

METHAMPHETAMINE
1. Learn as much about crystal as you can.

2. Take a close look at what role crystal plays in your life.
3. Learn the basic steps to stopping crystal.
4. Learn how to stay clean.
5. Address major "holes" in your life that you may be trying to fill
with crystal.
INTRODUCTION I 11
HOW TO USE THIS BOOK

This book is written for a broad audience because so many different
types of people use methamphetamine — straight or gay, young or old,
male or female, blue-collar or professional. Many references or examples

in this book refer to gay men because, while they form only a tenth of
the total meth-using population, it is estimated that up to 30 percent
of gay men have tried meth, and this is a community at extremely high
risk (almost six times greater than the general U.S. population) for meth
addiction. Nonetheless, I also want to clearly emphasize that all "peofle
are susceptible to the addictive potential of crystal. In addition, this book

is meant for others who want to find out more about methamphetamine:
a nonuser who is concerned about a loved one's crystal use, a therapist or
drug counselor who is looking for a reference about methamphetamine,

and even the curious reader who picked up this book purely for personal
edification. For this reason, the chapters are written so that you can pick
and choose whichever strikes you as most relevant or interesting. You do
not need to read the chapters in any particular order, and I encourage you
to read them in whatever order seems most comfortable and meaningful
to you. However, if you realize that you are addicted, I strongly encourage
you to read all the chapters, to get the most balanced and complete under-
methamphetamine and how to overcome your addiction.
standing of
Methamphetamine has many street names, depending on the com-
munity where it is being used. These names include: crystal, meth, blue
meth, ice, hot ice, super ice, glass, crank, Tina, Chrissy, chalk, working
man s cocaine, chicken feed, and yellow barn. All names refer to the same
drug: crystal methamphetamine. Some people distinguish "crystal "
as a
form of methamphetamine that is purer than the usual powder that people
buy. However, most people do not make this distinction and use the term
"crystal" for any form of methamphetamine. Because the names "crystal
and "meth" are so common, for the sake of convenience, these two terms
will be used throughout this book.
Regarding the use of the word "addict," please refer to chapter 4 for
a full discussion of what addiction is. The term "crystal addict" is used
frequently in this book, and it is used without any judgment. There is no
implication that the crystal addict is a bad person or has weak charac-
ter. In fact, this book gives a strong message that addiction is a medical
disease, similar to diabetes and hypertension, without blame or moral

value. However, since the organ affected is the brain, the symptoms are
manifested in feelings and behaviors, so it is difficult to see addiction
as anything beyond personality. Like diabetes and hypertension, addic-

tion requires treatment; otherwise it can be devastating and, ultimately,
deadly.
Some may take offense at seeing themselves being referred to as

"addicts." However, this term is intentionally used throughout the book
in an attempt to destigmatize the term and make readers accustomed to
it. There is nothing magical or mystical about addiction, and by reading it
and saying it out loud, you take away some of the power that it has held by
being a taboo word — ^ûnthinkable to say, and therefore unapproachable.
Once you can approach the idea of being an addict, you have something
to work with, and you can really begin to fight the addiction. If this book
makes it a little easier for an addicted reader to admit that he or she is an
addict, then this small offense to a few is worthwhile.
__ PART
1
UNDERSTANDING CRYSTAL
METHAMPHETAMINE:
Getting to Know Tina
Up Close and Personal
STRATEGY:
Learn as Much about Crystal as You Can
Objectives:
• Learn exactly what you are dealing with— know thy
friend and thy enemy.
• Understand what crystal does in your body to know
why you feel and act the way you do.
• Understand better what feelings are yours versus

what are crystal's effects.
• Use your knowledge to strategize about how to
manage crystal in your life.

1
BLUE METH, SUPER ICE, CRANK,

TINA, CHICKEN FEED:
A Short History of Crystal Methamphetamine
METHAMPHETAMINE HAS BEEN around for
a long time, familiar to different people
under different names, including: crystal, meth, blue meth, ice, hot
ice, super ice, glass, crank, Tina, Chrissy, chalk, working man^s
cocaine, chicken feed, and yellow barn. Its an old drug, related to
amphetamines, though much stronger.

Amphetamines were first developed in 1887 in Germany as a diet aid,
though initially they were not popularly used. By the 1920s, people started
to use amphetamines to improve energy and to help with dieting and
weight loss. They were later used by the U.S. military during World War II
to help soldiers to combat fatigue during long hours of duty. However, their
use was complicated by many side effects, including anxiety, agitation,
aggression, inability to sleep when soldiers needed rest, and addiction.

Later they were used as a panacea for such diverse purposes as weight
reduction and the treatment of narcolepsy. Currently, amphetamines are
still prescribed for attention-deficit and hyperactivity disorders, chronic
fatigue, weight loss, and narcolepsy.
Methamphetamine, the more powerful cousin of amphetamine, was

created in Japan in 1893, though as in amphetamine's early days, it
long remained in experimental laboratories, far from public use. Like

amphetamine, methamphetamine was also used by Japanese, American,
and German military personnel to combat fatigue during World War II.
Unfortunately, its problematic side effects were even worse than with
amphetamines. After the war, military surplus supplies of methamphet-
amine reached the public market in Japan, causing an epidemic of meth-
amphetamine abuse that was at least temporarily curbed by Japanese
government legislation that limited the public supply.
Similarly, in the United States, after World War II there was a surplus of
another amphetamine called Benzedrine, which was released to the gen-

eral population. Benzedrine was used by truck drivers and others whose
jobs required long hours. Amphetamine was similarly used during the
Vietnam War to help soldiers stay awake. Upon their return to the United
States, some soldiers continued using different forms of amphetamines,
which served as an introduction to the drug culture of this country.
During the latter half of the twentieth century, U.S. pharmaceutical

companies legally produced methamphetamine for domestic medical uses,
as outlined above. However, because of the clearly abusive and addictive
qualities of meth, after the passing of the Federal Controlled Substance
Act in 1970, methamphetamine became tightly regulated and very dif-
ficult to obtain. This had a significant impact on production and usage of

crystal. Production was mostly driven underground, into private garage or
basement labs. Motorcycle gangs, such as the Hell's Angels, became major
producers of methamphetamine, creating and serving a large market of
illicit users. Often carried in the crankcases of motorcycle riders, it earned
the nickname "crank."
Methamphetamine also gained quiet popularity among nonfringe mem-
bers of society, including professionals, such as doctors, lawyers, and
university students who needed to stay awake for long hours to work. It
continued to be prescribed by doctors to treat obesity, though this use

became tightly restricted, as it became clear that methamphetamine was
an extremely harmful and addictive drug.
In the 1980s, therewas a spike in meth use among the working class
in Hawaii and California, with supplies coming from Mexico and Asia.
Gradually, it spread eastward to the rural Midwest and Southeast, and
A SHORT HISTORY OF CRYSTAL METHAMPHETAMINE I 1?
eventually to urban areas on the east coast. Meth abuse became particu-
larly heavy among people in rural communities, where its production is
easier. The manufacturing process is messy with strong, noxious smells,
volatile reactions, and the potential for dangerous explosions. This is one
reason that production flourished in rural areas rather than densely popu-
lated cities, where production would be dangerous and conspicuous to law
enforcement. The ingredients to make methamphetamine are simple and
easy to obtain, including substances such as over-the-counter deconges-
tants and a common chemical used as a fertilizer, another reason for the
drugs popularity in rural areas.
In rural areas, neither law enforcement nor the medical community

were prepared to deal with such a proliferation of drug use. Some indi-
viduals in those areas have reported its easy availability as the reason they
became addicted. Others have described using it as a way to combat bore-
dom in small, isolated communities with "nothing much else to do."
Other affected communities included lower- and middle-class young

women looking for quick and easy ways to lose weight. In a country where
obesity continues to be a worsening problem, the social pressure to be
thin has been ever-increasing. Crystal provided women with a cheap
alternative to commercially branded diet programs and expensive gym
memberships. Battling low self-esteem and poor body image, meth gave
these people an artificially boosted sense of self-confidence and an ability
to accept themselves, though this lasted only while they were taking the
drug. Once they stopped, their mood and self-esteem would plummet
into depression, their appetites would increase, and they found them-
selves no better off than before. Unfortunately, many found themselves
on an endless merry-go-round of escalating meth use to avoid facing the
body image issues that the drug so successfully hid. Even worse, the crash
can cause depression connected to body image, which can make the self-
esteem even lower than before using meth.
POPULATION FOCUS: CRYSTAL IN THE GAY COMMUNITY

Crystal has been receiving a large amount of media attention as a 'gay
drug" used by a subgroup of gay men in the United States. In absolute
numbers, heterosexual meth users far exceed gay users, who make up an
estimated 1 1 percent of all meth users in the United States. However, as
far as the percentage of the community that has been affected, the gay
male community has been particularly hard-hit. Estimates of the number
of gay men in the U.S. who have ever used meth have been reported as
high as 20 to 30 percent, in contrast to 5.3 percent of the general U.S.
population. In addition, the association of crystal with unprotected sex
binges and the prevalence of HIV make this drug a particular concern for
this community.
Though the crystal epidemic started in largely heterosexual working-class
communities, it gradually became a party drug for certain middle- to upper-
middle-class gay men in urban communities, who used it to fuel their energy
in all-night dance parties called circuit parties, in which some people would
dance for twelve to eighteen hours. It has gradually become the drug of choice
at these parties, which attract up to eight}^ thousand people, and which have
become multiparty marathon events lasting for several days.
Before crystal. Ecstasy and ketamine had been the most popular drugs
at circuit parties. Those drugs were appealing because they induced feel-
ings of relaxation and social connection, both having significant meaning

to a group of people that felt disconnected and rejected by a homophobic
society Gay men from all over the United States and from other countries
converged on a particular city for a party, an occasion to feel connected
and accepted. At these parties, they would celebrate their sexuaHty and
embrace their sense of belonging, which was a powerful drawing force for
tens of thousands of men. Favored drugs at these events enhanced the
profound emotional experience of bonding and freedom; "breaking the
rules" by using illegal drugs did not seem so bad, as gay men had already
"broken the rules" of society simply by being born gay.
As circuit parties quickly became a lucrative industry, and the number

of parties at each circuit event increased, the length of events increased
from one-night dances to festivals lasting from three to seven days. Crystal
gave partygoers the stamina to attend all the events and to enjoy extended
holidays. Although drugs had always been a part of the circuit party scene,
the draw these parties gradually shifted. Rather than being primarily a
place where gay men could reclaim a sense of belonging, the appeal of
circuit parties became more about the freedom of heavy drug use. Surveys
showed that over 90 percent of circuit partygoers admitted to using drugs,
with from one to seven different drugs used during a single day. The highly
addictive nature of crystal increased the appeal of these parties even
A SHORT HISTORY OF CRYSTAL METHAMPHETAMINE I 19
more, and for some, "the circuit" itself became an addictive phenomenon.
Though people went to circuit parties with the notion that they were pur-
suing a sense of community, bonding, and better self-esteem, the positive
feelings didn't last long after the parties ended and the drugs wore off.
Many circuit parties that were actually fund-raisers for HIV organizations
became events where heavy drug use and unsafe sexual behavior resulted,
and this likely led to the transmission of HIV and other sexually transmit-
ted diseases in many of the partygoers.
At the turn of the millennium, a significant change occurred in the
way that gay men used crystal —more were smoking it. The circuit-party
community, made up predominantly of middle- to upper-middle-class,
well-educated Caucasian men, and the rave community, originally mostly
Caucasian middle-class teens, used crystal primarily by snorting it. This

was a relatively easy way to use crystal, and it was faster and gave a ''better
high" than swallowing it. Smoking crystal was initially looked down upon
because it was reminiscent of the frightening crack epidemic of the 1 980s
that predominantly affected the urban poor. Gay circuit partiers, rave kids,
and people in rural areas didn't identify themselves with the crack-using
population. The stigma of doing something akin to smoking crack kept
most people from smoking crystal, and snorting crystal let them pretend
that they didn't have a drug problem: "We're not like those crackheads of
the eighties. We just use crystal to have fun."

But as crystal addiction became stronger, people were willing to go to
further lengths to get a better high. Smoking was the natural next step. "At
least it's not shooting up," some people said. But unfortunately, smoking
is almost as addictive as injecting. The amount of meth that is absorbed
through the lungs is exponentially greater than what is absorbed through
the nose, and drug delivery to the brain is that much stronger and faster.
So smoking is a much more efficient way of using meth. And it is that
much more addictive.
Not only does absorption of crystal differ from person to person, but the
high feels different, as well. Some people don't feel that they have to stay
awake all night, and they can go to sleep much sooner because the high
doesn't last as long. But what comes along with a shorter high is a quicker
withdrawal. When people started partying by smoking crystal with the
intention of a quick partying session, many soon found that they simply
were smoking more often, sometimes every ten or fifteen minutes, trying
to maintain their high and to chase away the looming crash.

After breaking the barrier to smoking crystal, the remaining obstacles
to heavier use were easy to overcome. Injecting crystal intravenously, or
slamming, became more common. Crystal users looked for more ways to
use the drug, and among some gay men, mixing crystal with a small amount
of water fluid into their rectums became a new method,
and squirting the
called booty bumping. In particular, booty bumping constricts the blood
vessels in the rectum, and there is less rectal pain during anal intercourse.
This allowed booty bumpers to have even longer, harder sex as bottoms
(partners receiving anal insertion) more easily, with the experience of hav-
ing a "hungry hole" that enhanced or increased desire for sex even more.
This also allowed for more damage during sex to the lining of the rectum,
which increased the risk of catching sexually transmitted diseases.
Another major social change happening around the turn of the mil-
lennium was the explosion of Internet sex sites. In particular, gay-male
sex sites made finding sex partners as easy as ordering food for delivery.
Internet surfing, Internet shopping, and Internet sex (aka cybersex) were
becoming their own addictive problems. Crystal meth, which intensifies
both sex and other compulsions, in tandem with Internet sex sites became
an unstoppable combination.
Internet sex sites developed their own culture and secret language, such
as PNP, meaning "party and play," a code meaning that people were look-
ing to have sex while using drugs, almost always with crystal.
This was also a time during which some gay men were becoming more
complacent about using condoms. There may have been a decline in the
HIV because of the development of so many effective medications.
fear of
The younger generation of gay men had grown up in the era of the "HIV
cocktail": By this time there were already several medications to fight HIV,
and many people started to think of HIV as a controllable chronic illness,
like high blood pressure. Young gay men of this era never had the experi-
ence of watching partners and loved ones die from AIDS, so the specter of
HIV was much less frightening. During the intensity of crystal sex, wearing
condoms just did not seem that important.
A description given by a heterosexual man who used crystal illustrates
the perspective of someone high on the dangers of HIV. This man had
regular sex with female prostitutes, never used condoms, and he gave the
following description of his experiences:
I was totally clear. I felt more clear than I ever felt without cr\'stal.
It's not like I was cloudy and fuzzy like with alcohol or heroin. It's
not like I forgot. I still knew about HIV, and I knew all the infor-
mation about how to keep safe and that 1 should use condoms, et
cetera, et cetera. I've been in rehab and I've been lectured about
HIV a million times. But if you think of a car rushing at ninety
miles an hour, if you're on the street and that car passes right by
you, it's scar\^ as shit, and you want to run for cover. But being
on crystal was like being in an airplane. The higher 1 felt, the
more exhilarating it was, and the more determined I was to have
sex. There wasn't anything else I wanted more at the time and 1
was like an unstoppable machine. Nothing was going to hurt me.

And the higher I was flying in that airplane, the car traveling at
ninety mph looked smaller and smaller, looking slower and less
important. Really. Like when you look at little cars on the road
from an airplane window and they just look like slow little ants.
1 still knew about HIV 1 guess, but it was like one of those little
specks. In comparison to my need for sex, it just didn't matter as
much. So why use a condom?
In fact, many people who use cry stal don't use condoms while having
sex. And this has had a direct impact on the spread of sexually transmit-
ted diseases. In particular, rates of HIV and hepatitis transmission have
increased, and various studies and health-care agencies estimate that about
one-third of recent HIV infections have occurred during cn^stal use.
A Self-Destructive Binge Brian's STORY {
'
I
I Finding out that he had HIV was devastating for Brian. Despite knowing
that HIV IS now a nnuch more treatable condition than in the 1980s. Brian
was terrified. However, instead of trying to take care of hinnself. he went
on a self-destructive binge. He recalls thinking. "Well, if I'm fucked, I'm
fucked, so what does it matter'?" He went on an extended crystal-and-

sex binge, using the Internet to invite men to his apartment over four
I
j
days, having marathon sex without even stopping to eat. He does not
recall how many people he had sex with, but he knows that he never used
a condonn. He recalls the sex feeling nnuch nnore intense, "topping" others
with even more aggression or wanting "to be fucked by lots of guys, as if
I were worthless and being used by other people." Later, in therapy, he
talked about more complicated feelings, such as relief: Brian had been
afraid of getting HIV for so long that he actually felt liberated. He could
have sex without worrying about getting HIV because he already had it.
He considered the possibility that one of the reasons he had sex without
condoms, in addition to the crystal high, was that he wanted to become
HIV-positive— if he were positive, he thought, his experience of having sex
wouldn't be plagued by the constant fear of catching HIV.
While smoking crystal and having sex with one man, Brian had a sei-
zure. He does not recall what actually happened (typical of seizures), but
he assumes that the man called 91 1 and fled his apartment— he was told
by the hospital that the ambulance personnel found the door of his apart-
ment open, and Brian lying naked and unconscious on the floor
In therapy, Brian discussed how crystal helped him cope with the
depression, fear, and anger he felt about getting HIV. It allowed him a
brief relief from his sadness by elevating his mood, and it made him
feel confident and powerful rather than frightened and powerless. While
Brian believed some part of him may have wanted to get HIV, he also felt
tremendous anger at himself for getting HIV, and he wanted to punish

himself. In addiction, he felt angry in general— at HIV, at gay men, and
at the world. The rough intensity of the sex was an outlet for his pent-up
rage, wrapped in the deceptive guise of "hot sex."
Getting HIV, and his self-destructive binge, was a wake-up call for
Brian. He considers himself lucky because he believes that many people

he saw at sex parties or met online were in the same state of denial
or self-destruction, but unlike him, they continued their behavior. Even
though he ended up in the hospital, the humiliation of being found naked
and unconscious by the ambulance team and possibly his neighbors, as
j
well as the immediate possibility of dying, shook him awake: while HIV
could possibly kill him if he did not start taking better care of himself,
crystal was definitely putting him closer and closer to death.

CRYSTAL AND WOMEN—

WHAT ARE SPECIFIC ISSUES FOR FEMALES?
While a substantial number of women use or are addicted to meth,
different studies find widely varying numbers. For example, in a meth
study conducted by the University of California, San Diego (UCSD),
only 24 percent of people responding to recruitment efforts were female,
roughly one third the number of males. However, in another study from
the University of California, Los Angeles (UCLA), which recruited sub-
jects from a methamphetamine treatment center, females almost equaled
males in number. Interpreting these data is difficult. In the UCSD study,
it is not clear how and where potential subjects were solicited. If ads were
placed in papers read more by men, or in places frequented more by men,
then this could explain the dramatically greater number of men compared
to women in the study. On the other hand, the UCLA study recruited
subjects from a methamphetamine treatment center. Hypothetically, sup-
posing women were more likely to seek help for addiction than men, the
greater presence of women in that study would not accurately reflect the
proportion of female to male meth addicts outside of treatment settings.
The absolute number of women using meth remains unclear, but it is cer-
tain that many women use meth and do so with serious consequences.
Biologically, women's bodies handle crystal differently than men's.
Women produce a form of the enzyme dopamine beta-hydroxylase that

is slower than the form produced by men. This enzyme breaks down
dopamine into adrenaline, which increases energy, elevates mood, and

can also cause anxiety. It is likely that this difference results in gender-
specific experiences of the drug. According to the UCLA study, the most
common motivations to use crystal reported by women were to get high, to
have fun, and to increase energy, which were similar motivations for men.
However, there were also some significant differences. While improving
energy was one of the most common reasons women reported, this was a
much less frequent reason for men. While 14 percent of women reported
using crystal to enhance sexual pleasure, 23 percent of men felt sex was
an extremely important factor in their use. The most striking difference
was that 36 percent of women identified weight loss as a reason they used
meth, compared to only 7 percent of men. Clinically, we see the use of
crystal for weight loss in drug rehabilitation programs and in hospital units
treating women with severe anorexia and body-image disorders.
Though the UCLA study did not find sexual pleasure to be one of the
primary motivations for women to use crystal, research consistently shows
that using the drug while having sex intensified sexual pleasure in women
similarly to how it has been reported by men. The powerful effect on
sexual desire and behavior caused by crystal puts women at a higher risk
of catching STDs or becoming pregnant.

Because meth can cause such intense hypersexuality, it can also be used
as a date-rape drug. Usually we think of date-rape drugs as sedatives that
make the victim mentally clouded or unconscious. With crystal, however,
the victim remains wide awake and vibrantly clear. Because it stimulates
sexual appetite so powerfully, the victim may be willing to have sex with
almost anyone, including many people whom she would never even con-
sider she were sober.
if The drug changes her judgment so much that she
is literally "not the same person," and she would pursue sex much more
aggressively. It was likely she could also feel so compelled by sex that she
might disregard her normal precautions and put herself at risk for STDs
and pregnancy.
Given the hypersexual effects of crystal, unintended pregnancies are a
considerable concern. Unfortunately, there are few studies examining how
often this occurs. One study in Hawaii found that out of 546 deliveries,
1.4 percent of the babies tested positive for methamphetamine, which is
a surprising figure considering that the general prevalence of meth use

in the United States is 4.0 percent, and Hawaii is considered to have a
significantly higher percentage of active meth users.
Crystal causes serious compUcations to both mothers and newborns.
There have been numerous case reports of pregnant women using meth
who came to the hospital with similar complications: premature deliv-
ery, preecclampsia/ecclampsia (dangerously high blood pressure before
and during delivery), maternal cerebral hemorrhage (bleeding inside the
mothers brain), and cardiovascular collapse (failure of the heart and circu-
latory system due to depleted dopamine and adrenahne) because mothers
chronically exposed to meth were not able to tolerate anesthesia. In most
of these cases, the mothers died.
Babies of meth-using mothers also suffered serious complications,
including compromised placental blood flow (inadequate oxygen and nutri-
tion to the developing fetus), premature delivery, low APGAR scores (poor
color, breathing, and general responsiveness of the newborn at the time of
delivery), and abnormal development of the baby's nervous system. Studies
of rats exposed to meth during their gestation showed abnormal seizure
activity, reflecting abnormal development of the surface of the brain.
Women must be aware that crystal's sexual effects can cause unplanned
pregnancies, resulting in harm to the mother and child, with consequences
as serious as death.
TEENS AND CRYSTAL— WHAT'S HOT AND WHAT'S NOT

The 2002 National Household Survey on Drug and Health reported
that 1.5 percent of teenagers reported ever using crystal. Fortunately, this
group has shown a slight decline in meth use —although very modest— in
the past year. Adolescents have unique concerns about crystal use that
should be known by teens, as well as parents, teachers, drug counselors,
and policy makers.

Studies of teenagers in Taiwan, albeit culturally different from adoles-
cents in the United States, can warn us of important issues that may also
apply to teens in this country. Taiwanese studies showed that meth use
in teens was associated with general behavioral problems; lower quality
of caregiving, such as disrupted parental care and lower caregiver educa-
tion; having adolescent peers who also use meth; and an alarmingly high
rate of suicidal thoughts — 16 percent—within the past year. Research at
Duke University found that among American youth, recent meth users
were more likely to be female, aged sixteen to seventeen years old. Use of
meth in these teens was highly associated with criminal activity and recent
problems with alcohol.
Research shows that adolescents have a pattern of using meth that is
distinct from adults. It is associated with environmental factors that must

be addressed, such as quality of parental care and the presence of meth
in schools. In addition, teen-specific education about meth should be
developed as a preventive measure —the fewer peers using meth, the lower
the risk that a new teen will pick up the drug. With regard to depression,
whether it is a cause for meth use or meth use results in more serious
depression, teens should be carefully monitored for signs of problems
with mood. Further studies hopefully will shed light on what aspects of
crystal make it so much more appealing to female teens, whether it is the

appetite-suppressing and weight-loss effect or another cultural or female-
specific biological response to methamphetamine.
Last, there is mounting evidence that adolescent brains are particularly
susceptible to damage from crystal. Brains continue developing in humans

until early adulthood, so their reactions to drugs, as well as the damage that
drugs cause, can differ greatly between adolescents and adults. Animal
studies have already shown that adolescent brains exposed to metham-
phetamine show more structural damage than adult brains, particularly
in areas such as the basal ganglia, and show greater deficits in cognition,
meaning ability to think and learn. While human studies have shown the
immediate problems associated with meth use in teens, animal studies
have shown that teens who use meth may experience significant long-term
problems with thinking, mood, behavior, and neurological disorders, such

as Parkinson's disease.
CRYSTAL CAN AFFECT ANYONE: SOME SOBERING STATISTICS

The appeal of methamphetamine is broad because it is such a power-
fully addictive drug. Once it gets a foothold in any community, its use
spreads quickly, and significant numbers of people can be affected — in all
age groups, ethnicities, religions, and sexual orientations. I gave detailed

examples of two specific communities, gay men and heterosexual women,
as illustrations of how particular groups can be affected. But the risk of
meth addiction exists for people of any type, manifesting itself in different
ways within each community.

Though there have been cycles of meth addiction in the past, this cur-
rent wave is worse because of the rapid social changes in recent years,
including growth of the Internet, greater ease of obtaining sex, and easily
accessible information on how tomake meth. Combined with other ill-
nesses such as HIV and hepatitis B and C, we are currently witnessing an
even greater public health disaster.
Despite U.S. government efforts to stem the rise of crystal use, it con-
tinues to increase and cause problems. According to the Drug Abuse
Warning Network, the number of crystal-related emergency room visits
increased from 10,447 in 1999 to 17,676 in 2002. The American Society

of Addiction Medicine confirms this study and reports that states in the
A SHORT HISTORY OF CRYSTAL METHAMPHETAMINE I 2?
Midwest are particularly affected: there, 70 to 80 percent of hospitals

reported that meth was a factor in at least 10 percent of their patient
visits. In addition, 47 percent of those midwestern hospitals surveyed

identified crystal as the most common drug-related cause of emergency
room visits. Some reasons included severe chemical hums of people try-
ing to manufacture crystal, traumatic injuries linked to aggression, and
paranoid behavior while high. Meanwhile, the demand for treatment of
meth-related incidents or addiction has increased by 69 percent, causing
a sharp rise in hospital costs; however, 63 percent of the hospitals also
reported that they didn't have enough resources to meet the heavy demand
for emergency care.
The initial concern about crystal and gay men was due to the increase
in risky sexual behaviors. However, the preliminary findings of a study
by the California Department of Health Services, Office of AIDS, show

that sexual behavior of exclusively heterosexual men seems to follow the
same pattern. Straight men using crystal, compared to a matched group

of noncrystal-using straight men, were significantly more likely to be
recently sexually active, have anal sex with women, have casual or anony-
mous sex, have multiple female sex partners, have sex with women who
injected drugs, and have ever exchanged money or drugs for sex.Condom
use did not differ much because its rate of use was generally low in all
heterosexual men.
I STRONGLY EMPHASIZE that crystal can affect anybody While there has
been considerable media attention on crystal use in the gay male com-
munity because of its connection to HIV, gay men make up only a small
minority of the total number of crystal users in the United States. This is
extremely important to understand. The needs of all populations affected

by crystal must be addressed, and funding for treatment services should
be directed to all of the various communities. In addition, the recent ten-
dency of many people to think of crystal as a gay drug may fuel homopho-
bia and distract attention from the real problem of the potential dangers
of crystal methamphetamine to all people.
WHAT EXACTLY IS CRYSTAL
METHAMPHETAMINE?
METHAMPHETAMINE BELONGS TO a class

of drugs called stimulants. Stimulants
act on your brain in a way that increases alertness, and they work pri-
marily on the neurotransmitterdopamine, as well as another chemical

called norepinephrine (more commonly referred to as adrenaline).
Dopamine is a chemical that affects not only your brain, but your heart,
lungs, muscles, blood vessels, stomach, intestines, and even the blood
vessels that line all the muscles and skin throughout your entire body. It
has many functions depending on where it's acting. Methamphetamine

is a very close cousin to amphetamine, differing only by the addition of
a methyl group, a small cluster of atoms with a carbon atom and three
hydrogen atoms.
Though the difference in the molecular structure is small, the effect
that this small cluster of atoms has is tremendous, making methamphet-
amine the most powerful stimulant that exists. Other stimulants include
amphetamine (sold under various brand names, such as Dexedrine and
WHAT EXACTLY IS CRYSTAL METHAMPHETAMINE? I 29
Figure 2-1. Chemical structure of methamphetamine and similar molecules.

Adderall), methylphenidate (Ritalin, Concerta, Metadate, Focalin), pemo-

line (Cylert), and caffeine. Various herbal remedies, such as ephedra (also
called ma huang), ephedrine, guarana, and ginseng have stimulant proper-

ties. Even though they are touted as "natural remedies," their stimulant
effects function in the same way as pharmaceutical^ produced drugs, and

they are not necessarily any safer.
WHAT DOES CRYSTAL DO IN THE BRAIN?

Crystal is a particularly potent stimulant because it increases the amount
of dopamine available to the brain in two ways: First, it causes brain cells
to release dopamine into the space between itself and the adjoining brain
cell. The second brain cell has specific receptors into which the dopamine
fits. Like a key inserted into a lock, dopamine hits these specific receptors
and causes a chain reaction of events that result in the second brain cell
sending a signal. Hence dopamine is called a neurotransmitter, because

it transmits signals among brain cells.
NORMAL SIGNAL TRANSMISSION NORMAL

NERVE SIGNAL
o
POSTSYNAPTIC
D DOPAMINE
DOPAMINE RECEPTOR
Figure 2-2. Normal signal transmission in dopamine brain cells.
ENHANCED TRANSMISSION
STRONGER
D D NERVE SIGNAL
1 .DOPAMINE
VESICLES RELEASED
2. MORE DOPAMINE
IN THE SPACE
3. STRONGER SIGNAL
TRANSMISSION
D DOPAMINE
DOPAMINE REUPTAKE
^-^ TRANSPORTER
Figure 2-3. Signal transmission in dopamine brain cells with enhanced dopamine release.
The second action of methamphetamine is that it prevents the reuptake

of dopamine back into the brain cell In general, brain cells are good con-
servationists: they try to recycle neurotransmitters so that cellular energy
isn't wasted on making large amounts of dopamine —the brain can simply
reuse what it has already made. But meth blocks the recycling centers,
called dopamine transporters, so that dopamine is trapped in the space
between brain Dopamine starts to accumulate, like water in a sink
cells.
that's become clogged. The second brain cell is bombarded with more
dopamine, and this results in increased stimulation of the cell and a much
stronger signal transmission.
ENHANCED TRANSMISSION
1 .BLOCKED
DOPAMINE REAPTOR
RECEPTORS
2. BLOCKED
DOPAMINE
RECYCLING
3. INCREASED
DOPAMINE
IN THE SPACE
4. INCREASED SIGNAL
, TRANSMISSION
Figure Signal transmission in dopannine brain cells with blocked reuptake.
Blocking dopamine reuptake is the primary way that cocaine works as

a stimulant. Meth is much more powerful than cocaine because it does
the same thing as cocaine, but it also causes an outpouring of dopamine,
as shown in figure 2-3. Imagine a sponge, sopping wet with a fluid called
dopamine. Crystal squeezes the sponge and grips it tightly, so that the
sponge can't reabsorb any of the dopamine. The outpouring of dopamine
when the saturated sponge is squeezed is the initial rush that meth us-
ers feel. This huge gush is also associated with the production of free
radicals, chemically active particles that cause damage to the body. Free
radicals have been implicated in causing genetic mutations, cancer, cell
death, and aging. I will talk more about this in chapter 22.
When the brain has been flooded with dopamine that is unable to be
recycled, the level of dopamine within the brain rises dramatically In com-
parison to brains without any drug exposure, cocaine raises dopamine to
levels 400 percent higher than normal. Methamphetamine is much more

powerful and causes a 1,500 percent increase in dopamine. Clearly, this

is far from the brain's natural state.
Although dopamine affects many parts of the brain and body, the effect
most important to our discussion is upon the area called the nucleus
accumhens, which sends a dopamine-mediated signal to the ventral
tegmentum. These two brain sites connect by a bundle of brain cells
called the mesolimbic pathway, or the "brain-reward circuit." This is one
of the areas of the brain that is most powerfully associated with pleasure.
However, it is also highly associated with addiction.
WHAT DOES USING CRYSTAL FEEL LIKE?

IS IT REALLY THAT GOOD?
The human brain is made up of 20 to 50 billion cells. While the gen-

eral arrangement of these human brains, between
cells is the same in all
individuals there are countless small differences in how these cells are
arranged. Each experience you have and each new piece of information
you learn causes small changes in the connections between brain cells.
Also, anything you expose your body to, including food, drugs, and chemi-
cals in the environment, has an impact on the way your brain develops.
So each person's brain is unique. In addition, your body is unique in the
way that your particular liver breaks down toxins, how easily your body
stores drugs in fat cells, and how well it excretes drugs from your kidneys.
Therefore, there is some variability in how each person experiences crys-
tal, physiologically speaking. Nonetheless, there are some experiences
that are common to most people, and in the following general descrip-
tion, the majority of people have many or most of the symptoms, though
perhaps not all:
Depending on how meth is taken, its effects can start almost

immediately or may take a while. Swallowing methamphetamine
or squirting it into the rectum can take 20 to 40 minutes to feel
the effects. Snorting meth gives an effect in about 2 to 10 min-

utes. Smoking or injecting causes an effect almost immediately
People using meth often feel an initial rush of euphoria, followed
by a strong sense of well-being and boosted self-confidence.
Their moods are elevated, and if they were feeling depressed,
crystal may quickly lift them out of the blues and into an
extremely happy state. Their senses are heightened, and sights
and sounds may seem sharper and more vivid. On the other
hand, just as if they have had too much coffee, some people
may also feel jittery and anxious, or even panicky. In general,
most people feel a tremendous boost of energy and confidence,
believing that they can accomplish almost anything. People who
were socially withdrawn suddenly are able to come out of their
shells and see themselves as outgoing, charismatic personalities.
Their brains work at a faster speed with more ideas coming to

them. The boost in confidence makes these ideas seem brilliant,
and there's a strong need to talk to others about these ideas, with
people talking more and at a faster rate.
'M Meth helps people to concentrate and do very focused activities.

This can be great for the tired worker who has too many things
to do and not enough time in the day to do them. This can be
particularly dangerous because once people see themselves per-
forming extraordinarily well, they may start to expect a level of
work that's only possible by continuing to do more meth. Then
working without the drug may seem slow, difficult, and relatively
unproductive.
When people use larger amounts of meth, their goal-directed
behavior become extreme, resulting in the compulsive repeti-
tion of an activity. This could be a stereotyped motor activity,
meaning repeating a single type of movement over and over again,
such as rocking, chewing or grinding teeth, wringing hands, or
fidgeting with objects. The behavior may extend to more complex
activities, such as vigorously cleaning an entire house or search-
ing in a purse for a ticket stub for 30 minutes. While the person
is high, the activity makes sense, and there is a strong feeling of
determination and purpose to the activity.
In the extreme, the compulsive things people do on crystal are
not productive. When they are sober, they may look back at what
they've done, realizing that they've written volumes of nonsensi-
cal scribbling or spent hours rearranging a bookshelf that was
already organized. But when they were high, their inflated confi-
dence and strong determination tricked them into thinking that
I OVERCOMING CRYSTAL METH ADDICTION
they were working on a brilliant project that made perfect sense

at the time.
Like other stimulants, methamphetamine is an excellent appetite

suppressant. People lose their appetite, and they may become so
focused on some activity that they forget to eat at all. People have
lost tremendous amounts of weight while doing crystal, though
not in a healthy way. Rather, their bodies become malnourished,
they lose healthy muscle, and they lack the vitamins and nutri-
ents they need for optimal health.
Crystal can cause dry mouth and tooth grinding, and, along with
malnutrition, it can also cause osteoporosis. When it is used
frequently and for long periods of time, this combination of
factors can result in severe dental problems, recently given the
nickname meth mouth, that literally destroy teeth. The artifi-
cial boost in their self-esteem and the intense focus of attention

on other things distracts crystal users, who may be completely
unaware or unbothered by their dental decay.
Figure 2-5. "Meth mouth." Photo taken by Michael I. Barr. DD5
In gay dance clubs and at circuit parties, crystal is becoming

more and more the drug of choice, rather than Ecstasy or ket-
amine, which used to be the most popular drugs. Crystal helps
people in these venues to dance longer and to feel more of the
sexual energy of the pickup scene. Many partygoers feel a boost
in self-confidence, which helps them feel sexier and more attrac-
tive, and so they behave more sexually aggressively than usual
and have more courage to try to meet someone or proposition
someone for sex. Fueled by the energy of crystal and the strong
allure of a sexually charged environment, circuit partygoers are
able to stay at marathon dance parties with little-to-no-sleep for
several days. They become so involved in the dancing that they
forget about all other activities, including eating, drinking, and,

for those who have HIV, taking their medications, which depend
on a strict time schedule. Alternatively, they may disregard the
precautions they need to take for medications that they have
already taken —combinations of meth with some medications,
such as certain HIV medications, anti-infectious agents, and
antidepressants, can be dangerous or even deadly. While users
feel and think they look great, they may actually appear haggard
and wasted. When the lights go on at the end of a club night, the
sight of the last stragglers still dancing on crystal is not pretty.
Crystal users may disregard precautions concerning safer sex, or
the quality of sex may be rougher, because they feel more aggres-
sive and powerful, or they feel an insatiable hunger for sex. The
intense need for sexual gratification often overshadows concerns

about HIV, other sexually transmitted diseases, and pregnancy. For
some, the excitement of playing with danger adds to the high.
WHAT HAPPENS IN YOUR BODY WHEN YOU USE CRYSTAL?

Crystal works primarily on dopamine, which has receptors not
just in the brain but throughout the entire body. Dopamine is one of the
chemicals that the body uses in the fight-or-flight response, which kicks
in when one s brain senses there is an emergency or a threat to one s sur-
vival. Dopamine makes the heart beat harder and faster, and it constricts
blood vessels in certain parts of the body, like the skin, nasal passages,
and the intestines, so that blood can be redirected to other areas, such as
muscles, which are more needed in a fight-or-flight situation. Blood pres-
sure increases, and pupils dilate to let in more light and enable one to see
a predator or an escape route better.
Here is a breakdown of what happens:
The heart: During this reaction, the heart is working overtime,

meaning that it needs to have more oxygen (delivered to organs
via the blood). However, high blood pressure can actually prevent
blood from getting back to the heart because it makes it difficult
to move blood through the vessels. In some cases, stimulants

can cause blood vessels that feed the heart itself to constrict and
prevent the heart from getting an adequate blood supply. This is
what is called a heart attack, and it's possible that crystal users
may suffer multiple tiny heart attacks over time, or more rarely, a
large and serious one with obvious chest pain. Other symptoms
of a heart in serious distress may include pain radiating from the
chest to the jaw, left shoulder, or left arm; dizziness; shortness of
breath; nausea; and vomiting. Any of these symptoms mean that
someone should call 91 1 immediately, and the person should be

taken directly to the emergency room.
The digestive system: Because it is receiving less blood, the whole
digestive tract slows down. This is one of the reasons that appe-
tite decreases and bowel movements become less frequent.
With extremely high doses of meth, the intestines can even
suffer bowel ischemia, meaning that the muscles and lining
of the intestines can die because of insufficient blood supply

Fortunately, this is rare.
The kidneys: The kidneys filter all of the blood that flows through
the body. The blood vessels and filtering units, called neph-
rons, are delicate and require a delicate balance of blood flow
through them. They can be damaged by elevated blood pressure.
However, they also require a minimum constant blood supply in
order to stay alive. When people use crystal, they may initially
have high blood pressure, but when they binge and do not drink
fluids, they become dehydrated, and their blood pressure can
become low, resulting in low blood flow to the kidneys. With
an insufficient blood supply, kidney cells may die, and if there
is enough damage, the kidneys may go into failure. People who
use meth should remember to drink fluids regularly. If they are
dancing in a hot room and sweating, they are losing even more
water, and it's even more important to keep drinking liquids.
The muscles: Crystal cranks up the whole body's system, and
body temperature can become elevated. This, together with the
several-day dance marathons of circuit parties, can increase the
breakdown of muscle. Muscle breakdown products, such as cre-
atinine phosphokinase (CPK), are toxic to the kidneys when
they are present in high concentrations in the blood. This is
another reason to keep drinking fluids to save one's kidneys — to

dilute the toxic effects of CPK. When muscle breakdown is
extreme, this is a condition called rhabdomyo lysis, which can

also damage kidneys and lead to kidney failure. People with
rhabdomyolysis are usually given intravenous fluids to hydrate
them as quickly as possible, dilute the toxic muscle breakdown
products, and flush the toxins out. To avoid ever reaching that
extreme state, remember to keep hydrated!
FOCUS ON CRYSTAL AND THE BRAIN: WHAT'S REALLY

HAPPENING INSIDE YOUR HEAD
Numerous studies in humans and in animals have shown that crystal
causes changes in brain function and damages brain cells involved in
dopamine and serotonin transmission. In particular, crystal decreased the
function of brain cells in the thalamus, a central area that relays motor,
sensory, and emotional signals to different parts of the brain; and the stria-
tum, which deals with reward-linked motivation, planning, and impulse

control. A study at the Brookhaven National Laboratory in Upton, New
York, found that nine to eleven months after crystal users quit the drug,
they were able to regain some activity in the thalamus, but the striatum
remained impaired.
Some people argue that crystal does not ''destroy" brain cells; however,
several studies demonstrate that it damages farts of certain cells, some of
them permanently. These cells can be compared to the long microfibers
that carry telephone signals. If the ends of the microfibers are destroyed,
the signal cannot reach its target. Similarly, even if an entire brain cell
does not die, the destruction of just the end of the brain cell has pro-
found effects on how well it is able to transmit the signal it is supposed
to. Scientists nicknamed the effect of crystal on brain cells "pruning,"
meaning that the tips of affected brain cells are "cut off," much as a
bush is pruned. Damaged brain cells try to compensate by sprouting new

branches, but studies show that the function remains impaired.
Functional imaging of the brain with PET (positron emission tomog-
raphy) scans shows what parts of the brain are active during different
activities, such as resting, concentrating, or thinking different emotional
thoughts. These imaging studies have consistently shown differences in
the way that the brains of heavy crystal users function compared to brains
that have never been exposed to the drug. These differences are in areas
that use dopamine, as well as glutamate, which is used in the frontal cor-
tex. Recent studies show that longtime stimulant users may be more prone
to Parkinson's disease and other movement disorders, which are related
to damage in areas of the brain that function with dopamine.
Supporting the data from PET scans, studies that directly test the men-
tal function of heavy crystal users compared to nonusers show that the
former group demonstrate impaired mental function, particularly complex
thinking that involves adapting to changing situations, various aspects of
memory, weighing judgments, and decision making. Unfortunately, these
are areas of thinking that you must use to keep yourselffrom falling hack into
drug use. Without these faculties, it is much more difficult for an addict to
fight off relapses. Continued crystal use literally changes the brain so that
it becomes harder to mentally resist the urge to keep using.
Recently, research has found that the meth-related damage to sero-
tonin neurons is associated with less control of aggression and impulses.
If these functions are weakened, then an addict's ability to resist the temp-
tation of using a drug again is even harder. In even more ways, the brain
becomes hard-wired to keep itself on cr\^stal.
WHAT HAPPENS IF YOU TAKE TOO MUCH CRYSTAL?

Stimulant toxicity is common with regular users. What is it like
when someone uses too much crystal?
1 Anxiety and difficulty sleeping are common, even with lower

doses and infrequent use.
Rather than euphoria or positive mood, some people experience
agitation, irritability, and impatience.
With a tremendous strain on the heart, crystal can cause heart
attacks, which can be small and painless or significant, with tre-
mendous chest pain or even death.
C The increase in brain activity can cause seizures in some people,
especially if they have a history of seizures or are simultaneously
taking other drugs or medications that increase seizure risk.
With high doses and frequent or regular use, people can become
paranoid, feeling that they are being followed or watched. They
—
may start keeping the shades drawn and react to small noises,
fearful that someone is following or harassing them. Paranoia can
become quite elaborate, with beliefs that the CIA or neighbors
are following them. They can start to have hallucinations
hearing voices, seeing things, and feeling sensations such as
bugs crawling on their skin.The reason for these symptoms is
overstimulation of the dopamine system in the brain. Too much
dopamine is one of the brain malfunctions in schizophrenia, and
the behavior of people with severe stimulant toxicity can mimic
that of paranoid schizophrenics. Many meth users have been
admitted to psychiatric hospitals and treated with medications
for schizophrenia because the symptoms appear identical.
There is a "kindling" effect with stimulant psychosis, meaning

that the more a person experiences psychotic symptoms, such
as paranoia and hallucinations, the greater is the likelihood of
experiencing psychosis the next time he or she uses meth, and
the psychosis can become increasingly severe and last longer,
even days to weeks after the person stops using cr}^stal.
3
HOW IS CRYSTAL MADE?
CRYSTAL IS RELATIVELY easy to make. Early

methods were based on recipes using
phenyl-2-propanone, mercuric acid, aluminum foil, and methylamine.
More recent production methods are simpler, made with over-the-coun-
ter cold remedies, such as the nasal decongestant Sudafed (pseudo-
ephedrine), and lithium from rechargeable batteries.
While some of the ingredients, such as pseudoephedrine, are safe,

many of the ingredients are extremely toxic: mercury, aluminum, anhy-
drous ammonia (commonly used by farmers as fertilizer), toluene (a
solvent used in paint, glue, and gasoline), methanol (an extremely toxic
form of alcohol used in industrial processing), ether (one of the first
chemicals used for surgical general anesthesia), lye, muriatic acid (con-
centrated hydrochloric acid, used to clean mortar and brick), iodine, and
rubbing alcohol. These ingredients are mixed and heated, and elements
are extracted to form methamphetamine.
In addition to problems associated methamphetamine itself, there are
dangers of using street meth because it is unlikely to be pure. Some of
the toxic agents listed above may not have been fully processed, and may
HOW IS CRYSTAL MADE? I 4I
therefore still be in their original form in what is sold on the street. In
particular, mercury, methylene, and aluminum are well known to cause

serious medical problems, such as brain injury and damage to the brain,
liver, and kidneys.
Crystal has been produced in thousands of small basement labs through-
out the country, particularly in rural areas, where the strong, noxious smells
and the potentially explosive reactions attract less attention. Recently, the
federal and local governments have been clamping down on meth labs,
closing down 17,000 labs in 2002 alone. In addition, many localities
have been passing legislation to limit the supply of such ingredients as

nasal decongestants, making them more difficult to buy in any significant
quantity. During this recent period, production has shifted to "superlabs"
outside the United States, to countries where supplies are easier to obtain
and production can continue with less interference from law enforcement.
The U.S. Drug Enforcement Agency estimates that 80 percent of all meth-
amphetamine used by Americans is produced in Mexico. Still, thousands
of small basement labs within the United States are continuing to produce
crystal from recipes that are readily available on the Internet.
A particular danger of online recipes is that they are not regulated or
reviewed by anyone to guarantee their authenticity or accuracy. And many
when they are correct, they
of the recipes are crude, so even are likely to
leave many contaminants and unprocessed toxic chemicals in the final
product.
fiere is an unedited excerpt from a Web page of one "basement" manu-
facturer, describing how he makes meth:
Shake the jars till pills are completely broke down, then let
the jars sit again for 4 hours or until the Heats is completely
clear. Once clear cyphon the heat off (Not the powder stuff at
the Bottom you don't want this it will fuck your dope up). Well
anyways syphon the hear off with a piece of the sergical tubing
syphon this into a pyrodex baking dish... if it's this color you have
done good at cooking the dope now to add colemans fuel fill the
far full just anough room for shaking now add 1-2 teaspoons of
red devil lye let the jar site aofr about 5 mins then place lid on
the jar and shake the hell out of it.
— http://totsei.com, accessed April 12, 2005

The writer seems marginally literate and unsophisticated, yet he is han-

dling dangerous chemicals. The recipe is crude and filled with potential for
mistakes that could allow the final product to contain chemicals far more
toxic than methamphetamine. But his incoherence notwithstanding, the
mixture described above has likely been snorted, smoked into the lungs,
or injected directly into the bloodstream of many unfortunate people.
The impurity of crystal is not just a frightening supposition. A 2003 :
study of methamphetamine, released by the White House Office of Drug 1
Control Policy, reported that from 1994 to 2001, the average purity of
methamphetamine found in the United States had decreased from 71.9
to 40. 1 percent. That means that of the crystal that you buy on the street,
up to 60 percent is not methamphetamine — rather, it could contain fill-
ers, other drugs you never intended to take, and toxic leftovers from the
production process.
At the time of this writing, several states and municipalities have
passed laws to limit the availability of pseudoephedrine to any single
individual. Since then, domestic production in basement labs has dra-
matically decreased, and the majority of manufacturing has shifted to
Mexico. Despite production in Mexican superlabs, which churn out large
volumes at a rapid pace, "factory-produced" crystal is not necessarily any

safer than basement-brand crystal. There are no restrictions or guidelines
on the production of methamphetamine in these illegal superlabs. Recent

reports indicate that the purity of crystal produced in superlabs is indeed
higher, but the unexpected and the unpredictable increase in potency has
resulted in a number of overdoses, ER visits, and deaths.
Consider this cautionary reminder: In 2004, there was a health alert
concerning children who may have eaten certain candies produced in
Mexico that contained chili or tamarind. Because of poor regulation of
these legal products, it was found that many of the candies, which had i
been exported to American markets, contained dangerous levels of lead,

|
and thus children who ingested the candies may have suffered lead poison- .
ing. Imagine how much less controlled foreign factory production of illegal
substances is. Let the buyer beware.

:
PART
t
UNDERSTANDING ADDICTION:
What Is It and Do You Have It? I
STRATEGY:
Take a Close Look at the Role
Crystal Plays in Your Life
Ob j ectives
• Learn precisely what addiction is.
• Learn the distinct attributes of crystal that make it
so addictive.
• Learn about the nnany uses of crystal besides just
getting high. Is it really just a recreational, fun activity,
or is it a crutch that helps with other needs?

• Carefully examine your use of crystal to see if it fits
the pattern of addiction.

MEDICAL DISEASE OR WEAK
PERSONALITY? WHAT IS ADDICTION?
BEFORE DISCUSSING THE addictive proper-

ties of crystal, it is important to under-
stand the concept of addiction itself. "Addiction" is difficult to define
because the term is used so commonly in the English language. The word
is 'Tm addicted to soap operas," or
casually used in such situations as
''I'm addicted to chocolate. Even among different medical specialties,
'
there is disagreement about how exactly to define addiction.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV), a diagnostic reference book published by the American
Psychiatric Association (APA), uses the term "substance dependence" to
define drug addiction. Using this new term with its specific definition
avoids the confusion of all the different meanings that "addiction" has. In
this book, the word "addiction" refers to the APA definition of substance
dependence.
In essence, DSM-IV defines substance dependence as a pattern of con-
tinued use of any substance despite the fact that it has become harmful to
the person using it. This means that even though a drug causes problems
in a person's health, daily function, or other important aspects of life, the

addict is unable to stop using it.
The fundamental concept of substance dependence is that a person no

longer has control of the drug or the use of it — rather, the drug is control-
ling the person, whether by psychological or physiological means. Despite
the growing problems the drug creates, the addict continues to use or
increase the amount and frequency of use.
''Loss of control" does not necessarily mean that an addict is aware of
any problem — this is a major reason addicts allow drug use to increase to
such an unhealthy extreme. The longer a drug is used, the more distorted
the drug user's judgment becomes, and behavior that would never have
been acceptable now becomes tolerable if it is necessary to allow the
addict to keep using the drug.
For example, a successful attorney who had a perfect attendance record
at the office, often working later than her colleagues, starts occasionally
blowing off steam on Friday nights by doing a couple of bumps of crystal.
Eventually her Friday routines regularly include doing meth, then going
to bars to pick up men for casual sex. Over a few years, with increasingly
longer and frequent crystal binges, she gradually finds herself calling in
sick on Mondays because of crashing from weekend-long binges She
doesn't question it because she feels that she had always overworked, and
she believes that giving herself this enjoyment in life is a much smarter
way to live.
In another example, a teenager who was always a model student tries
meth so that she can study longer hours for her exams. She starts using it
regularly to get her work done and gets hooked. Like most teens addicted
to crystal, she eventually stealing. Having no job and only a small allow-
ance from her parents, she secretly pawns valuables from her home so she
can buy more meth, even though in her precrystal days, she would never
have imagined herself stealing from her family.
DSM-IY DEFINITION 01 SUBSTANCE DEPENDENCE

"
I I
SUBSTANCE DEPENDENCE: A maladaptive pattern of substance use,

leading to clinically significant impairment or distress, as manifested by
three (or more) of the following, occurring at any time in the same 12-
month period:
WHAT IS ADDICTION? I 47
1. Tolerance, as defined by either of the following:
a. A need for nnarkedly increased amounts of the substance to

achieve intoxication or desired effect.
I b. Markedly diminished effect with continued use of the same

amount of the substance. «
2. Withdrawal, as manifested by either of the following:

j
a. The characteristic withdrawal syndrome for the substance.
\ b. The same (or a closely related) substance is taken to relieve or

avoid withdrawal symptoms. I
3. The substance is often taken in larger amounts or over a longer
period than was intended.
4. There is a persistent desire or unsuccessful efforts to cut down or

control substance use.
5. A great deal of time is spent in activities necessary to obtain the

substance (e.g., visiting several doctors or driving long distances),
use the substance (e.g., chain-smoking), or recover from its
effects.
6. Important social, occupational, or recreational activities are given

up or reduced because of substance use.
7. The substance use is continued despite knowledge of having a
persistent or recurrent physical or psychological problem that is
I likely to have been caused or exacerbated by the substance (e.g.,
current alcohol use despite recognition that an ulcer was made

worse by alcohol).
Reprinted with permission from the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision Copyright 2000. American Psychiatric
Association.
In practical terms, the DSM-IV breaks down addiction into three broad
areas:
The first is a physiological adjustment of the body so that it needs more

of the drug. This is either apparent by needing to use more to get the same
amount of a high, or feeling terrible when the drug is stopped, because
your body needs the drug in its system just to feel normal. The terrible
feeling of withdrawal is what keeps many people continuing to use, even

when they are not pursuing a high.
The second concept covered by the definition of substance dependence

is that the space it takes up in your life grows larger and larger. You gradu-
ally use more of the drug, you spend more time and money using it, and
you find yourself going to great lengths to get it. Its importance grows to
the point that it outweighs other things in your life, and when given the
choice between the drug and other pleasurable or important activities,
such as spending time with friends or family, meeting deadlines, or doing

your job properly, the drug seems increasingly attractive.
The drug becomes so important that you end up going to great lengths
to get it, finding yourself doing things that you ordinarily wouldn't: spend-
ing money that should have been used for paying bills; going to danger-
ous neighborhoods or inviting dangerous people into your home, to buy

drugs from a dealer; going to many different doctors, feigning illnesses
and symptoms to get more prescription pills. Before becoming addicted,

someone might never have done these things, but once addiction sets in,
putting oneself at risk, shirking responsibilities, avoiding loved ones, and

lying seems trivial compared to the need to use more drugs.
The third concept is loss of control. The physiological or psychological
need for the drug becomes a monster, though thismay develop so gradu-
ally it goes unnoticed. Over time, a drug user may spend less time with
friends and family and more time with other people. But as addiction
sets in and becomes stronger, even worse things happen, and the addict
takes greater risks while using drugs, becoming estranged from family and
friends, developing health problems directly related to drug use, engaging
in unsafe activities while being high, dropping or flunking out of school, or
losing a job. Despite these negative consequences of drug use, the addict
cannot stop. Loss of control can be so complete that it may seem that the
addict has even lost control of logical thinking. For example, a heavy crys-
tal user may find that even though he knows that his drug use is causing
him to feel paranoid and fearful, he does not want to stop. In the past he
would never have let his life deteriorate to such a low, but addiction hijacks
the brain and now it seems he does not even care about the frightening
paranoia —the most important thing in the world is doing more drugs.
5
WHAT ALL THE HYPE

IS
ABOUT CRYSTAL?
Is It Really More Addictive Than Other Drugs?
FIRST,A FEW BASICS ABOUT HOW THE BRAIN WORKS:

BRAIN FUNCTION 101
As MENTIONED EARLIER, deep in the brain lies a bundle of neurons (brain

cells) called the mesolimbic pathway, or the "brain-reward circuit/' This
bundle travels from an area in the brainstem called the ventral tegmentum
to another area called the nucleus accumbens. This deep brain structure is
nicknamed the "primitive brain" because it is shared by most animals and

developed early in the evolution of species. All things that are vital to living
are controlled by the primitive brain. This brain area controls your breath-
ing, maintains your heartbeat, and tells you when it is time to eat, sleep,
and wake up. It also controls behaviors such as eating and sex, of which
we are aware and over which we have some limited control. The primitive
brain functions are very powerful and difficult to override. For example, if
you try to stop breathing, assuming you don't give up from sheer distress,
you eventually pass out, lose consciousness, and start breathing again. The
primitive brains wins. Similarly, if you fly from New York to London, your
primitive brain is still functioning on New York time. Even if you know
its morning in London and you have to wake up, your primitive brains
insists that its still nighttime, and its a struggle to feel fully alert. This
phenomenon, commonly called jetlag,"
'
is an example of the primacy of
the primitive brain.
The brain-reward circuit, which lies in the primitive brain, is Mother
Nature's way of tricking animals to repeat behaviors that are important for
the long-term survival of the species. In the evolutionary^ model, behav-

iors that help an animal to live and have offspring are the most important
because they help the entire species to survive. Therefore, activities such
as eating and sex are tied to the brain-reward circuit. The species would
eventually die out without eating or having sex. They are activities that
most creatures do with pleasure, and there is a "compulsive" need to
eat and have sex repeatedly. In this manner, the brain-reward circuit has
helped humans, as well as most other species, to survive.
Humans also have a higher, more sophisticated part of the brain

that developed much later in evolution: the wrinkled outer part of the
brain called the neocortex (meaning "newly-developed cover"). This is
where complex rational thinking occurs. The neocortex in humans is more

developed than the cerebral cortex of any other species. The wrinkles on
the outside of the human brain developed because there was not enough
room on the surface of the primitive brain to accommodate the growing
cortex, so as it continued to grow, it folded over itself, creating wrinkles,
which are called sulci. The human brain, with its highly evolved cortex,
is what gives us much higher powers of reasoning and logic compared
to other animals. This is the part of the brain that is rational and tells
overweight people, "You need to lose weight, so you should stop eating so
much." fiowever, control centers for appetite and the drive to eat do not
reside in the cerebral cortex. They are in the primitive brain. This is one of
the reasons that it is so difficult to diet, despite the intellectual knowledge
that obesity is unhealthy —there is a constant struggle between the deeper
brain and the logical cortex..
As in the example of trying to hold your breath
and stop breathing, usually the deep brain wins.
This does not mean that it is impossible to overcome the deep brain
impulses. There are many success stories of people who overcame obesity
and lost impressive amounts of weight through diet and exercise. However,
the work is hard, as most success stories will attest. The battle between
the logical cortex and the primitive brain is a tough one.
WHAT IS ALL THE HYPE ABOUT CRYSTAL? I 51
ADDICTION IN THE BRAIN:

YES, THERE IS A MEDICAL REASON FOR IT
All drugs that are addictive somehow affect the brain-reward circuit.
The more directly they tie into this circuit, the more they cause compul-
sive, uncontrollable use of the drug. Alcohol, nicotine, heroin, marijuana,
cocaine, and methamphetamine all stimulate this pathway to some extent.
Because the brain-reward circuit sends its signals via dopamine, drugs that
increase the release of dopamine in this part of the brain are more addic-
tive. Cocaine and methamphetamine are powerful dopamine-enhancing
drugs, methamphetamine being the more powerful of the two.
The more often a drug stimulates the brain-reward circuit, the primitive
brain becomes more strongly programmed to repeat the behavior of using
that drug. Even months or years after stopping crystal use, people can still
have strong urges to use. Even after years of abstinence, when the craving
has been reduced to almost negligible thoughts, a small psychological trig-
ger, such as a familiar place or situation, or a small exposure to the drug is
all it takes to bring back the intensity of the compelling urge that has been
programmed into the brain.
The neurochemistr)^ of addiction is still a new field, and scientists are

continually learning more about how the brain works during drug use and
during the craving that pulls people back to using the drug again. In addi-
tion to dopamine, other parts of the brain are involved, such as the surface
of the front of the brain called the prefrontal cortex. Communication
between this area and the brain-reward circuit, as well as other areas,
determines behavior —how someone feels when exposed to a reminder of
a drug and how he or she makes a decision about what to do next (e.g., to
go ahead and use the drug or to move along and do something else). This
process is mediated by a chemical called glutamate. Recent studies reveal
that addictive drugs, and in particular methamphetamine, cause destruc-
tion of brain cells that mediate these glutamate signals, and after that hap-
pens the signals do not work properly. Therefore, even if a person rationally
knows that crystal has been destructive to his or her life, the brain has less
of an ability to take this information and translate it into rational behavior:
it becomes much harder to resist doing the drug again.
THE PSYCHOLOGICAL ASPECT OF ADDICTION:

WHEN DRUGS ARE USED AS A CRUTCH
The brain-reward pathway is one of many causes of addiction. Another
is the psychological relief that some drugs provide for emotional difficul-
ties, such as anxiety Crystal in particular can be a crutch for many dif-
ferent problems, such as depression, low self-esteem, fatigue, boredom,

and difficulty working long hours. It also decreases appetite in order to
lose weight. Most assume that people use drugs to feel high and to take
them away from reality. However, some people suffer so much from other
emotional struggles that drugs help treat the pain and "bring them back to
center," making them feel more "normal." For some people, drugs are a way
that they have found to deal with the reality of day-to-day living.
While stimulants are particularly good at enhancing low mood, "down-

ers," in contrast, such as alcohol, heroin, ketamine, and certain prescription
pills, such as Valium, Xanax, and OxyContin, can help with anxiety, provide
an "escape" from troublesome thoughts and feelings, or numb emotional

pain. This is an important concept to understand in drug treatment.
The take-home point here is that whatever drugs someone abuses, he
or she should think about what kind of difficult feelings the drugs might
be covering up. If there is a better way to cope, the drugs may not be so
necessary.
Whatever the reason is that you may have started using a drug, after
using it regularly to obtain emotional relief, your mind and your brain both
become accustomed to a "quick fix." There is an AA expression, "Hold your
belly," which encourages people to "stop your bellyaching and complain-
ing." This is not a cold and unsympathetic statement — it is a reminder
that you can tolerate some degree of frustration or uncomfortable feeling
without going straight to a drug to make it instantly disappear. "Hold your
belly" for a short time and let yourself sit with the feeling. Relearn that
you do not need the quick fix and that all problems do not need to be fixed
or erased immediately The strong need for immediate gratification and
a low tolerance for frustration are two psychological features that usually
develop in most drug addicts. Remember that you can survive if you wait
a little more productive route to address a problem, and
or take the longer,
that, you do something other than use drugs, you may be able to do more
if
than hide from the problem for a few hours ^you may even fix it! —
WHAT IS ALL THE HYPE ABOUT CRYSTAL? I 53
SOME SPECIFIC PSYCHOLOGICAIi CONSIDERATIONS

FOR GAY MEN
CRYSTAL may be particularly helpful with sexuality issues for gay men
I
because of internalized feelings that being gay is bad. Even those who are
I
completely "out and proud" may have deeply hidden notions that homo-
- sexuality is shameful. People have a tendency to internalize the values of
^ their parents and their community, even when they intellectually disagree
with them. A common example that illustrates the process of unconscious

'
internalization is a young boy who is angry at his parents and says, "I'll
never be like them when grow I up! I can't believe they treat me this way!" i
^ However, when the boy grows older, he observes his own behavior and
remarks with surprise, "Oh my God, I'm turning into my father!"
Gay males have a natural attraction to other males, and they experi-
ence pleasure engaging in sex with other men. Yet, at the same time,
they grew up in a society that to a great extent still labels homosexu-

ality morally bad and socially repugnant. Therefore having gay sex can
be like wandering through a flowery field filled with landmines. On the
surface it looks as if it should be easily enjoyable, but it is full of hid-
den emotional bombs that complicate sex with feelings of guilt and self-
hatred. When a man's biological urge to be with other men is criticized
by both the internal voices and the external attitudes of society, the re-
f
suit is ambivalence, confusion, and anxiety about having sex. The intense
hypersexuality of meth provides gay men an experience of unconflicted,
; unbridled sexual passion that many gay men have never experienced.
I Perhaps this is one reason why the gay male community has been par-
i ticularly affected by crystal. i
WHEN YOUR BODY NEEDS A DRUG JUST TO FEEL NORMAL:

PHYSICAL DEPENDENCE IN ADDICTION
A THIRD ASPECT of addiction is physical dependence on a drug. Heavy

drinkers who consume alcohol daily know the feeling of edginess, anxiety,
and tremors that occur if they stop drinking for more than one or two
days. Heroin addicts know the feeling of aches, chills, sweats, and intense
emotional misery when they stop using heroin.
Crystal can cause an acute withdrawal, with fatigue, hunger, increased

but irregular sleep, and depression that is sometimes so intense that people
feel suicidal. Fear of the crash is what keeps some people using continu-
ally, and it becomes less about chasing the high and more about running
away from the impending low. Depression and fatigue from a crash are
most noticeable during the first seven to fourteen days after stopping
crystal. Beyond that point, most people feel "back to normal," though the
brain is actually still not working up to its baseline level. After heavy and
regular use of crystal, it may take six to twenty-four months for someone's
brain to reach a level of function close to how it had worked before that
person ever used crystal.
I
DO YOU THINK
YOU MAY BE ADDICTED?
YOU USE crystal methamphetamine, how

IF
do you know if you are addicted? Not every
user becomes an addict, and of those who do, the time it takes to develop
an addiction varies. Some people are hooked immediately, and after just
one try, they feel so amazingly good that they know that have to use more.
However, for the vast majority of users, losing control of crystal is a gradual
process that is so subtle, it goes unnoticed until it is too late. This more
common experience of a slow development of addiction is consistent with
the current understanding of brain physiology. Each exposure to crystal may
cause a small but lasting change in the circuitry and function of brain cells.
After enough exposures, the neuronal pattern changes enough and the user
crosses a threshold where he or she can no longer resist the temptation to
use crystal. The brain pathways that mediate decision making have become
set so that using crystal is priority number one, regardless of what other parts
of the brain logically think or desire.
So how does this translate into practical terms? In general, addic-
tion means loss of control, but knowing when one has lost control can be
'
difficult to discern. There are several ways to assess whether you have a
problem with controlling crystal in The ''CAGE questionnaire,
your life.
developed in 1974 as a medical screening tool, has become a favorite of

general practice physicians who screen their patients for addiction. It is a
simple screening tool with the following four questions:
C: Have you ever tried to Cut down on your drug use?

A: Are you ever Annoyed when people mention your drug use?
G: Do you ever feel Guilty about your drug use?
E: Do ever you use drugs first thing in the morning
(an "Eye-opener")?
If you answer yes to two or more questions, there is a very good chance
that you have a substance-use problem. The CAGE questionnaire was
originally designed to screen for alcoholism, and it has been scientifically
validated and found to pick up approximately 93 percent of people with
alcohol dependency. Because of its high sensitivity and studies that dem-
onstrate its usefulness in different scenarios, the CAGE questionnaire
has been used to screen for addictions to other drugs, such as crystal
methamphetamine.
In addition to the CAGE questionnaire, here are some additional ques-
tions to ask yourself to help examine your drug use and level of control:
1 . How often do you use crystal and has your use been increasing? Do you
use crystal once every few months, only when someone offers it
to you? Did you start out this way, but gradually your use has in-
creased to every other weekend? Did you plan the increase in use
or did it sneak up on you? Has your use increased to every week-
end, and do you find that you can't wait for the work week to end
so you can use crystal again? Are you using crystal every day?
2. How muct) crystal do you use? Do you only have one bump, and then
you're good for the rest of the night? Have you increased to doing
several bumps or snorting lines? Are you able to do a bump and
then put the bag away and leave it alone until another day, or do
you usually have to go back for more? Have you noticed that the
amount that used to get you high is no longer enough, and you
now need much more?
DO YOU THINK YOU MAY BE ADDICTED? I 57
3. How much money do you spend on crystal? Has the amount been in-
creasing? Have you ever been in a situation where you did not
have enough money but somehow had to scramble for the cash by
borrowing money, going into credit card debt, leaving bills unpaid,
or selling things in order to pay for crystal?
4. How do you use crystal? Has this changed over time? Did you start
out snorting crystal, but later you started trying new ways to get
a better or more intense high, such as smoking or slamming, or

booty bumping?
5. Where are you using crystal? Are you using crystal only at rare social
events? Has become less of a social drug, and now you find
crystal
yourself using it alone? Has crystal become more of a solitary ac-

tivity except for sexual hookups? Have you become more isolated,
seeing fewer of your friends and family because you are too busy
using crystal?
6. Have you ever had health problems somehow related to crystal ? This could
include:
a. Chest pains that felt like you might be having a heart
attack
b. Catching a sexually transmitted disease because you were
having sex while high and not taking your usual safety pre-
cautions to protect yourself
c. Becoming pregnant because you felt so driven to have sex
while you were high that you didn't care that you weren't
using contraceptives
d. Panic attacks
e. Depression, anxiety, or suicidal thoughts after you stopped
using
f. Psychotic symptoms, such as paranoia that people were
watching you or eavesdropping, feeling that there was a plot
against you, hearing voices or seeing things, or feeling sen-
sations like bugs crawling on your skin
g. Dental problems from dry mouth, tooth grinding, and ne-
glecting your teeth
h. For people with HIV, finding that your CD4 count or vi-
ral load has been worsening, or having difficulty adhering

to your medication regimen because you were too busy
partying
If you answered yes to any of the above or have had any other
health problems related to crystal use, did you use crystal again,
even after realizing that crystal caused these problems?
7. Have you ever had trouble with your job because of crystal use ? Were you
ever late for work or had to call in sick because you could not
stop partying over the weekend, or when you did stop, you felt
too bad from the crash to work? Did your job performance ever
suffer? Did you ever get fired because of poor job performance or
poor job attendance due to crystal? Did you still use crystal, even
though you saw it affecting your work and possibly threatening
your livelihood?
8. Have you found yourself doing things to get crystal that you would never have
done in the past? Have you invited drug dealers who were unsavory
or potentially dangerous people into your home, or have you gone
to dangerous places to get crystal?
9. Do you find that crystal determines the people you spend your time with?
Would you be spending time with the same people if you didn't
share the bond of using crystal. Have you invited people into
your life that the old you would never have considered as pos-
sible friends? Have you been spending less time with important
people in your life who don't use drugs?
1 0. Is crystal a "take-it-or-leave-it" option, or has it grown into a requirement?
Did it begin as an occasional fun treat at social activities but
gradually became something you needed to enjoy yourself? Is it
something that helps you get through a rare (two or three times
a year) day of hard work, or has it turned into something you
frequently use to do your job? Is it an occasional 'extra spice"
you add during sex, or has it become a requirement for sex to feel
satisfying? Is crystal an option or a necessity?
1 1 .
Has the number of reasons you use crystal multiplied? Perhaps you started
out using it just to have fun at special parties, but you found more
and more reasons or excuses to use it: it makes things more fun,
itmakes you more confident, sex is much better, it's great to cel-
ebrate happy events, it's a lifesaver that rescues you from a sad
mood, it helps you when you're bored. Gradually, crystal has be-
come the "drug of all seasons," appropriate for any occasion. Do
you always have an excuse to justify using?
These questions are a good way for you to stop and closely examine how
you use crystal and how your use may have changed over time. If your
pattern has changed and grown over time while you have been blind to it,
you likely are developing an addiction.
WHAT IF I'M STILL NOT SURE?
If you've gone through this list of questions and you recognize that your
crystal use has changed over time and grown, but you are still unsure if
you are really addicted, the following exercises may help you check your
level of control:
EXERCISE 6-1 STOP USING CRYSTAl COMPLETELY FOR

ONE MONTH, STARTING TODAY
FIRST, take a good look at your response to reading this challenge. Did
you feel that it would be no problem? Was your first reaction a sudden
pang of fear that it would be difficult? Like many people, did you think
this exercise would be no problem, but you didn't want to stop today be-
cause there was a special event coming up or you had already planned
a special weekend or just bought a bag from your dealer? The last reac-
I
tion, probably the most common, is a sign that you are rationalizing, tell-
;
ing yourself that you have control, though "now is just not a good time."
For an addict, despite any plans to stop someday in the future, there
is never a good time to quit. If you truly do not need crystal, then you
can make it through any "special event" or difficult time without it. You
should be able to commit to this exercise and say with conviction, "Yes, I
can quit drugs for one month starting right now," and you should be able
to follow through on your commitment.
EXERCISE 6-2 MAKE A CONTHACT WITH YOURSELF

I
FOR THE NEXT SIX MONTHS
WHEN you are sober, on a piece of paper, make a six-month plan by an-
swering the following questions:
1. On how many occasions do you plan to use crystal during the next
six months (how many total occasions in the next six months, or
how occasions per month)?
2. How long do you plan to use crystal on each occasion? Just a
quick bump to kick off a night out with friends, several bumps
spread over the course of a night, or a three-day "weekend war-
rior" event at a circuit party or on vacation?
3. How much crystal will you use on each occasion and how much
money is a reasonable limit to spend during each month of the
entire six-month period?
U. In what situations are you going to use crystal? Only at parties,
while hanging out with friends, at sex clubs, or at home alone?

5. How you are going to use crystal? Snorting only, smoking, slam-
ming, booty bumping?
Answer these five questions on paper as specifically as you can,

making these the upper limits of what you plan to use over the next six
months. The upper limit should be similar to what your current use is,
or if you'd like to cut down, what you think is a smaller but reasonable
amount to use. Do not set limits that are more than your current use
because this is like planning to be "out of control."
Next to each item, leave an empty checkbox. At the bottom of the
paper, write:
I, [write your name], make a solemn commitment to myself to use

crystal according to the above guidelines until six months from to-
day's date. These guidelines were written by me, of my own free will.
In my current state of mind, believe these are reasonable limits to
I
using crystal. With this in consideration, understand that exceeding

I
; the limits, in any way and for whatever reason, indicates that am not I
able to control my use.

Sign and date the paper, make a copy, put each copy in separate sealed
envelopes, give one copy to a trusted friend, and keep one for yourself.
On your calendar, mark the date six months ahead, and over the next six
months, keep track of the information you outlined in the contract.
On the appointed day in six months, open the envelope and see
how you did. Take a look at your reaction to how you did, as well
as whether you think your guidelines from six months ago still seem
reasonable. If you were able to stick to your limit or remain below it,
congratulations! You may still have some control over your crystal use.
To make sure that you maintain control, I strongly suggest repeating this
contract every six months to keep track of your use to make sure that
it continues to be in your control.

Some people find that they exceeded their maximum limit, but they
don't mind. Despite the clause "in any way and for whatever reason,"
they feel justified in breaking the contract, giving excuses such as un-
foreseen "special circumstances." This demonstrates how reasons to
use insidiously multiply, and addiction constantly searches for ways to
trick the mind into using more. Addiction works silently in the brain, and
even though these people can't keep their meth use within their own
self-determined limits, they cannot see any problem.
Some find that their perspectives have changed over the six-month
period, and they decide that they grossly underestimated how much
crystal would be enough— they believe that they must not have been
thinking clearly when they wrote the contract. However, they wrote the
contract when they were in a distinctly clear and sober mental state.
Something in their minds is now different, and more crystal is now ac-
ceptable. This change is the process of addiction. While the person may
be unaware of any changes from six months prior, his or her need for
crystal has grown, and to accommodate the increased need, the per-
son's perception of what is acceptable has changed, as well.
Some people who were unable to stick to their contracts can clearly
see that crystal use is not in their control. They are fortunate because
this rapid insight is rare, and it can be a powerful tool that can be used
to overcome the addiction if they are motivated to stop.
If you exceeded the limits that you set for yourself, regardless of the
reason, there is no acceptable excuse. If you broke the contract, you do

not have control. You broke a contract that nobody forced you into. No-
body nnade any unreasonable dennands. You set your own "fair" ground
rules. If you cannot even follow your own wisfies, then clearly you are not
controlling yourself-crystal is.
EXERCISE 6-3 KEEP A LOG
BUY a little notebook and keep a crystal log. When you are sober and
nnotivated, draw seven colunnns on each page and label each column
with the following:
Date (When you used crystal)

How (How you used crystal— snorted, smoked, slammed, booty
bumped, etc.)
Amount (How much crystal you used)
Cost (How much you spent on crystal on that day)
High Rating (How good was the high on a scale of 0 to 10?)
Notable Events (Did anything notable happen? Did you finally ap-
proach the attractive person you've been too shy to meet? Did you
finally finish your work project? Did you catch an SID or uninten-
tionally become pregnant?)
Crash Rating (How intense was the crash on a scale of 0 to 10?)
TABLE 6-1
Sample Log
Date How Amount Cost High Notable Crash
Rating Event Rating
8/2/2004 Snorted 1/2 g $75 7 Amazing sex 4
8/9/2004 Smoked 1
g $125 9 Amazing sex
8/10/2004 Smoked 1
g 0— had sex 7 Amazing sex,
w/dealer blood from
anus
Keep it simple so that if you are using crystal or you are recover-
ing from a crash, filling in the information will require minimal effort. It
should take you one to two minutes maximum for each entry.
Periodically review your log. Over time, was there any change in
the frequency or amount that you used crystal? Even you don't see any
change, keeping a log, or even a more detailed journal, will help you see
more clearly what role crystal plays in your life and if that role is chang-
ing over time. Instead of turning a blind eye to your drug use, you will
be more aware of your usage pattern and any consequences of using
you may have— both good and bad. This will help you to keep your use in
check, and alert you if you are starting to lose control.

1
TAKING A LOOK AT CRYSTAL

IN YOUR LIFE:
Is Tina Just an Occasional Visitor or Has She
Become the Houseguest Who Just Won't Leave?
THIS CHAPTER EXPLORES how crystal fits in
your particular life and what role it plays

for you. This understanding is important for any person who uses crystal,
whether you are an occasional partier or a heavy user, a person in recov-
ery who is trying to stay clean, or someone who wants to continue using
crystal while staying safe and trying to keep it under control. Do you
use it as a fun party drug? Is it a way to deal with feeling bored? Does it
help combat feelings of shyness? Is it a way to help you feel better about
yourself? Is Tina the houseguest that was so fun and exciting when she
first arrived, but now she is torturing you because you cannot get her out
of your life?
WHAT ARE YOUR OWN REASONS FOR DOING CRYSTAL?

If you use must be something good about it. Unless some-
crystal, there
one tied you down and spooned it into your nose, you chose to try it. If you
did it again after the first time, there must have been something positive
TAKING A LOOK AT CRYSTAL IN YOUR LIFE I 65
about the first experience that made you go back for more. What was that
reason for you? Did new reasons develop over time? After hearing so much
talk about crystal as a demon, let's look at how at times it may have seemed
like an angel, helping you feel better in some way
Studies find that social or cultural groups in different parts of the coun-
try have distinct usage patterns, though even within those groups, each
individual uses crystal for his or her own reasons
Gay men commonly report using crystal at circuit parties and discos
and in sexual contexts, such as sex parties/clubs, Internet hookups, or
other sexual encounters, as well as during nonsexual activities. Among gay
men, some who have HW also use crystal to avoid depressive thoughts,
loneliness, and concerns about physical attractiveness thought to be lost
because of their illness. In addition, the power and confidence that crystal
gives them is a strong antidote for the powerlessness many of them feel
about HIV.
Heterosexual men and women reported different motivations. A 2004
study by Semple, Patterson, and Grant at the University of California-San
Diego found that primary motivations in this group were "to get high, to get
more energy, and to party, ' as opposed to enhancing sexual experiences.

Nonetheless, this group was still found to have significantly increased
sexual activity, with an average of 9.4 sexual partners in two months, with
an average of 2 1 . 5 unprotected vaginal sex acts, and 41.7 unprotected oral
sex acts during that time. A recent study by the California Department of
Health was the first to find that sexual activity among heterosexual men
appears similar to that of gay men, taking more risks: increased number
of female partners, more frequent anal sex with women, higher likelihood
of having sex with an injection drug user, and higher likelihood of having
exchanged sex for drugs. Clearly, even for heterosexual people, meth has
a powerful sexual effect.
Work is another common reason some people use meth. Manual labor-
ers working several jobs, as well as wealthier urban professionals in high-
pressure jobs with long hours, use meth to increase their productivity and
their ability to work longer hours.
In contrast, many people in the rural areas report using meth to combat
the boredom of living in quiet communities with little to do. It can help
even the most empty life feel vibrant and exciting.
Some, especially young females, seek meth's ability to decrease appetite
and cause weight loss. Severe obesity is still one reason that some doc-
tors in other parts of the world legitimately prescribe pharmaceutically
produced methamphetamine. Many people with eating disorders, such as
anorexia, and body image problems turn to meth as a diet aid. The clinical
picture then becomes even more complicated: anorectics typically see as
overweight and unattractive, no matter how skinny and malnourished they

become, and they need to keep star\'ing themselves to get even thinner;
however, meth boosts self-esteem and self-image, blinding addicts to the
grisly reflection they see worsening in the mirror. Anorectics hooked on
meth have a particularly complex self-image that fuels both their eating
disorder and their drug use. The reflection is a combination of good and
bad, ultimately reinforcing their belief that using meth and losing weight
is good for them.
HAVE THERE BEEN PROBLEMS IN YOUR LIFE

BECAUSE OF CRYSTAL?
Developing an addiction to meth is a process that, in most cases,
occurs gradually. If you are still early in your drug experience, or if you use
only once or twice a year, you may not have had any problems with addic-
tion. At least not yet.
If you use crystal a little more frequently but are not at the level of
partying every weekend or using every day, then be careful —watch for any
potential problems that may be lurking so that you can catch them as they
develop. You are in the blurry "intermediate zone," in which you actually
may not have problems with meth, or if you do, they are not obvious or
dramatic.They may seem so trivial that few people, including yourself,
would consider them alarming. This intermediate zone is a tricky place to
be because you may be teetering on the edge of addiction but there are
no big red flags to warn you of the danger. If you are in this stage, actively
assess your situation and how much control you really have. Your life may
seem fine now, but a downward spiral could be just around the corner.
If you are a hardcore user, using most days or using regularly with out-
of-control binges, and you have already experienced significant problems,
such as losing friends, becoming estranged from your family, losing your
job, failing in school, stealing or prostituting yourself to support your habit,
or jeopardizing your health and catching an illness, such as HIV, you are
"
TAKING A LOOK AT CRYSTAL IN YOUR LIFE I 6?
an addict. You may realize this and sincerely want to stop. Many people,
however, even in the face of serious problems, are still in denial. They tell
themselves countless excuses and rationalizations to convince themselves

that nothing is wrong: 'Those people really weren't my friends anyway.
Now that they don't call, I have more time to enjoy myself and use crystal."
"My family never really understood me anyway, who needs them?" "HIV
isn't so bad — it's a controllable disease that can be treated, so I don't have
to worry. What's the big deal?" Or "I was planning on quitting that job
anyway. I'm glad that I'm finally out of there.

Have there been negative consequences due to your crystal use? Are
you being honest with yourself about what they are or how much crystal
has changed your life? Are you honest with yourself about how important
those changes are to you, or have you been coming up with rationalizations
similar to the ones above?
THE DECISION MATRIX

A USEFUL TOOL to help you understand how crystal affects your life is the
Decision Matrix, a tool to screen for alcoholism that was developed by an
addiction psychologist named G. Alan Marlatt. It is called a matrix because
it is a grid, looking at both the positive and negative ways in which crystal
affects you. An example of the matrix is shown in table 7-1 , and a sample
matrix with one person's responses is shown in table 7-2:
TABLE 7-1
Decision Matrix
Positive, Helpful Negative, Problematic
USING CRYSTAL: j
Immediate |
Consequences i
USING CRYSTAL: 1
Delayed
Consequences
STOPPING CRYSTAL:
Immediate
Consequences
STOPPING CRYSTAL:
Delayed
Consequences
TABLE 7-2
Example of a Decision Matrix

USING CRYSTAL: I feel high. I can get anxious, jittery, or

I feel confident. panicky.
immediate
and attractive.
feel sexy Sometimes get chest pains.
Consequences I I
been able to lose

I've finally I can feel paranoid about
weight and keep it off. other people.
Sex is intense and amazing. I can become aggressive and
Sex is not as painful and I have gotten into fights.
can go for hours. I have had hallucinations of
I do amazing things in sex voices.

I never would have dared I don't bother with safer-sex
before. precautions.
I have great energy. I'll keep having sex, even if
I accomplish lots (at home, I notice I'm bleeding and

school, or work). should stop.
I feel quickerand smarter I've contracted sexually
I enjoy music and dancing transmitted diseases.
more. I gave someone else HIV.
I can meet sexual partners I got someone pregnant

more easily. unintentionally.
USING CRYSTAL: I can meet sexual partners I forget to take my HIV

more easily. medication because I'm so
Immediate
I feel more interested in focused on sex when I'm
Consequences
[Continued]
things even when there's high.
not nnuch to do at home. I get into arguments with my
partner or family.
I spend hours on the
Internet, like I'm stuck.
I putter around at home &
do things that later seem
stupid, like taking apart my
stereo.
I've lost interest in food.
I spend huge amounts of
money on crystal, even

when haven't paid my
I rent
or other bills.
USING CRYSTAL: I feel more a part of my I have a terrible crash.

group of friends. When I'm not high I feel
Delayed
more a part of the
feel depressed, tired, and
Consequences
I
glamorous crowd at circuit unmotivated.

parties. I've felt suicidal during a
I do better during exam crash.
crunches and pull up my I miss work because I can't
low grades. stop partying.
I don't have to deal with rela- I've missed work because I
tionship problems because felt so terrible during the

I just have good sex. crash.
I have a big group of friends I lost my job.
who share my interest in I care less about my family

crystal. and friends than I used to.
I have lost weight I really

didn't want to lose.
I got HIV.
My HIV or general medical
condition are worse.
I've begun stealing or pros-
tituting myself to pay for
more crystal.
STOPPING CRYSTAL: No more crashes. I can't hang out with my

Immediate I don't put myself at risk for usual social group.
Consequences STDs. I miss the high.

I feel more emotionally I don't feel as confident.
intimate with my partner— Sex is not as intense or
with the pressure off. we satisfying.
can make love better
1
rosiiive, neipTUi negdiive, rroDiemdiic
STOPPING My mood is a lot morG Gven 1 can't suddenly fix bad

CRYSTAL: and stable. feelings.
Immediate 1 can pay my rent this month. I'm bored out of my mind.
Consequences My appetite has returned. 1 can't work or study as hard
[Continued] or as long as i used to.
j 7 i I'm gaining weight again.

I feel unattractive.
STOPPING My health is improved. I'm losing my core group of

CRYSTAL: I have more energy in social friends.
Delayed general. I can't enjoy circuit parties or
Consequences I've regained or improved my clubs anymore.
relationships with my part- I can't seem to keep my
ner, family, and friends. friends if I don't do crystal
I spend less money, paid my with them.
debts, and even started Now I have to deal with my
saving money. HIV and can't just live
I don't find myself in the in the moment enjoying

same dangerous situations myself.
or with dangerous people. Now I have to deal with diffi-
My general work perfor- cult situations and feelings,

mance and attendance and I can't just make them
have improved. instantly disappear
I'm able to achieve important Without my core group of
things in my life like get- partying friends, I feel
ting a promotion or saving alone and isolated.

money for investments or
retirement.
To give you space to write in your answers, each quadrant is written on

a separate worksheet. (See Decision Matrix Questions 1 through 4, pages
71-77.) Under each question, there are 20 blanks to fill in. Try to come
up with at least 20 answers for each question. Usually people can easily
think of 4 or 5 answers. The reason to strive for 20 is to force yourself to
think of all the small and subtle ways in which crystal affects your life.
TAKING A LOOK AT CRYSTAL IN YOUR LIFE I ?!
QUESTION 1 WHAT ARE THE POSITIVE THINGS

ABOUT USING CRYSTAL?
STARTING an addiction exercise with this question surprises many peo-

ple who are accustomed to hearing that drugs are so evil that nothing
can be good about them. From experience, however, you know that this
is not true. If there were nothing good about crystal, you would never
have tried it and continued to use it after the first time. When answer-
ing this question, think about how crystal makes you feel, what areas in
your life it helps you with, what good changes happen when you use it.
In addition to "It feels great!" try to be more specific. How does it make
you feel great? Does it give you more confidence? Does it make sex more
enjoyable? Does it break you out of your shell in social occasions? Does it
alleviate boredom or work or home? Some people say that using crystal
was the first time they felt happy in years. Think about your own per-
sonal reasons and how meth may have made you feel better.
QUESTION 2 WHAT ARE THE NEGATIVE THINGS

ABOUT USING CRYSTAl?
IF you have read the preceding chapters in this book, you already know
the harm crystal can inflict, and you've probably heard other people say
what terrible things it has done to them. However, if none of those things
ever happened to you, then likely they don't have much personal impact
on you. In fact, if your experiences are completely different, you may feel
even more convinced that you don't actually have an addiction— how can
you believe all the bad hype if none of the things people say match your
experience? While it is helpful to hear about the many problems that
others experience from meth, it is most important to carefully consider

any harm that crystal has caused in your own life.
When writing your answers to Question 2, consider all areas of your

life. How was your mood during or after using crystal? Did it ever make
you feel anxious, panicky, or depressed? Have you ever heard voices or
I become irrationally paranoid? Think about your behavior during and af-
I ter using. Did you ever do something that you later regretted when you
^
were sober—having unprotected sex, spending all your money, getting
angry and yelling at a friend? Consider the effect crystal has had on peo-
ple in your life— how are your relationships with your friends, your fam-
ily, or your romantic partner? Has it had any affect on your work— have
you ever come to work late, not felt up to the job, or completely avoided
work and called in sick? Did you ever lose a job or come close to it be-
cause of meth? Did you start taking it to help with schoolwork but doing
schoolwork gradually seemed less and less important than doing meth?
Did you ever have any medical problems related to using? Did you spend
more money on crystal than you wanted to, perhaps putting yourself into
debt? Did you ever have to sell things, steal, or trade sex for money or
drugs because you were so desperate to get more? To what extremes

have you gone to get more meth? In addition to these examples, try to
think of every possible aspect of your life where craving, using, or crash-
ing may have adversely affected you.
QUESTIONS WHAT ARE THE POSITIVE THINGS

ABOUT STOPPING CHYSTAl?
THIS question may seem similar to Question 2, but with a twist. One way
to gain a deeper understanding of how something affects your life, imag-
ine what life would be like without it. Even if you don't think you need to
stop using crystal, hypothetically what positive changes could happen if
you stopped using? If you have intense crashes, could quitting help you
feel less depressed or irritable? If getting high or crashing has disrupted
i
your job, school performance, or relationships, could they be recovered or
t improved? If you add up all the money you spend on crystal in one month,
I
what other things could that money buy? How about the money you would
'i
spend on crystal in one year? If you haven't been eating so well or taking
your medications as regularly as you should when you are high, how do
you imagine your health would be if you stopped using?
QUESTIONS WHAT ARE THE NEGATIVE THINGS

ABOUT STOPPING CKYSTAl?
I
^
: DESPITE Nancy Reagan's well-intentioned tactic to fight drug addiction, ]
"Just say no," the battle is not so easy. While you identified many poten- ^
tial benefits of stopping crystal in Question 3, there will also be unpleas- -
ant things about stopping, whether it's the crash, finally facing difficult
problems that crystal made you blind to, or the sheer torture of trying to
resist the cravings. Would you miss it? If yes, then why? Would you miss
the excitement? Would you miss the self-confidence it gives you? What
would sex be like without crystal? If your social circle is a network of other
meth users, what would it be like if you stopped getting high with them, or
even worse, if you had to stop seeing them altogether? If you use crystal
to help you work, how would stopping affect your productivity? Would you
be able to keep up the fast pace that you'd set for yourself while using
crystal? Would you be able to keep up with your boss's expectations after
working as a meth-driven machine known for your extremely high level
of productivity? Just saying no is not so easy because there are a lot of
hurdles that will be difficult to jump over. If you don't examine the hurdles
in an organized way and systematically figure out how to clear them, they
may seem overwhelming and insurmountable. If that happens, you may
just surrender and decide to keep using.
If you are having trouble coming up with 20 answers for each question in
the Decision Matrix, use these general categories as guidelines:
M Specific mood before, during, and after using crystal
General emotional well-being

Physical health
Money
Time
Relationships (family, friendships, romantic relationships)
Job
:\ School
Activities/boredom
In general, how is your life different now compared to before you
ever tried crystal?
DECISION MATRIX QUESTION 1
What Are the Positive Things about Using Crystal?

What Are the Negative Things about Using Crystal?

What Are the Positive Things about Stopping Crystal?

What Are the Negative Things about Stopping Crystal?

REVIEWING YOUR ANSWERS
How DID THE experience of filling in these questionnaires feel? What

do your answers tell you? Were you surprised by how many ways meth
actually helps you? Was it difficult to think of 20 negative consequences
of using? After a Httle practice, did you start to identify the negative con-
sequences more easily? Did you realize how many different parts of your
life crystal affects? If you use crystal more than just a couple of times a
year, then likely it's had some effect on many, if not most, of the general
categories listed in the suggested guidelines for this exercise.
This section provides some ways to use the information from the
Decision Matrix to explore your relationship to crystal even further. It
may also give you a better general understanding of yourself as a person,

aside from aside from drugs — e.g., what difficult areas in your life does
crystal help you with, and if you stopped using drugs, how would you cope
with those problems? If you want to stop using, this section will show you
how to use your answers from the Decision Matrix to assist you along your
road to recovery.
Question 1: What Are the Positive Things about Using Crystal?
If you are unsure if you have a problem with crystal, starting with your
positive experiences with may feel like a safer place to begin self-explora-
tion. This book does not write off crystal as something completely evil.
Rather, it emphasizes the importance of understanding the drug from all
sides to protect yourself from the extremely high risk of addiction. How
significant are your positive experiences? If positives outweigh the nega-
tives, you may decide not to stop using crystal — at least not now. If the
positives don't seem worth the problems that crystal causes, then you may
decide to stop using crystal. Get all the information you can about the drug
and yourself, including the pleasures of crystal, so that you can try to make
a rational assessment of the drug's place in your life.
Even if you know that you need to stop using meth, identifying and
acknowledging your positive experiences on crystal is important. Sometimes
when people are so strongly determined to stop using, they actually block
out the good memories, saying with firm conviction that there was never
anything good about a drug that caused them so much harm. This is called
the ''honeymoon period," when people feel so determined to be sober that

they build up a false security and feeling of invincibility over crystal that
leaves them unprepared when cravings return. You can't work successfully
toward recovery without a complete understanding of your drug experi-
ences. If you hide information about your drug use, whether good or bad,
then your recovery is doomed.
In addition, recalling the good, as well as the bad, is an essential part
of saying goodbye to a drug, which can feel like an old and intimate friend
with whom your relationship has turned destructive. Saying goodbye is a
long process similar to mourning, in which you reflect upon your memories
and experiences, struggle with the idea of living without your old friend,
and eventually learn how to move on with your life. If you don't acknowl-
edge the good memories, you never go through the emotional challenge of
letting them go, and the happy memories stay hidden inside you, holding
on strongly to the hope that you will use again. With time, those lingering
positive memories grow into idealized fantasies that downplay the uglier
consequences of drug use. This distorted idealization is called "euphoric

recall," which can seductively lure you back into using.
Most important, identifying the ways that meth has been helpful to you
may clarify significant problems in your life that need work. Perhaps crystal
masked low self-esteem or provided a temporary Band-Aid for underlying
depression. Maybe using meth was the only way you could function at a
job that made unreasonable demands on you. Once you clearly see the
problems that crystal hid, you have an opportunity to actually fix them and
make a profound improvement in your life.
On the other hand, if you don't address the fundamental problems that
crystal covered up, those difficulties will never get better, and the urge to
reach for drugs will keep coming back. If you realize that you use crystal
to help you with self-esteem, depression, or an eating disorder, the drug

only hides the problem temporarily, and in the long run it makes it worse.
These are all good reasons to seek the help of a mental health professional,
such as a therapist or psychiatrist, so that these deep psychological issues
can be solved in a healthy and lasting way.
If crystal helps you combat boredom, ivhy is your life so boring? What
can you do to improve it? Instead of chemically hiding the emptiness, be
proactive and search for more interesting activities that meet your life
goals —take a class in something you've always wanted to learn about, pick
up a new sport, volunteer and learn more about the people and the world
around you —whatever sparks a little interest, go for it. Address the cause
of your boredom.
If this exercise has identified significant problems in your life, it is
important to tackle the fundamental problem than to rely on temporary

solutions that treat the surface only cosmetically. If you have a headache
because of a brain tumor, taking a painkiller may knock out the headache,
but the tumor is still there, and when the painkiller wears off, you feel
bad again, if not worse. Left untreated, the brain tumor will eventually
kill you, so hiding the symptoms is actually harmful. Now the importance
of Question 1 becomes even clearer. Take t list and use it to identify areas
in your life that you can improve. By addressing them with healthier and
more effective means, you can improve your general quality of life, as well
as keep yourself from slipping back into using meth.
Question 2: What Are the Negative Things about Using Crystal?
Now is the time to come clean and be as honest as possible with

yourself about any problems crystal has caused in your life. Write down
the worst things that you can remember, but also include the seemingly
little things —while each one may only seem like an annoyances, if you
find yourself writing a long list of them, you should begin to wonder why
you use something that causes you so many problems. If you have trouble
answering this question, go over it with a friend who loiows you well and
has seen you sober, high, and coming off crystal. It would be unusual if
you couldn't think of a single negative consequence from using meth. In

that case, you may have already developed a blind spot about your meth
use, and that blindness will prevent you from seeing any problems with
addiction growing worse, fiowever, if even the help of your friend, neither
of you can come up with any significant answers, then your crystal use
may not be a problem at this time.
If you believe that you need to stop using crystal, this list of negative
consequences is a wonderfully motivating tool to help you quit. Whenever
you feel the urge to use meth, take out this list to remind yourself how bad
things got when you used.
Choose the three worst consequences on this list and flesh them out.
For each, write a narrative describing that particular problem or specific

incident in detail. For example, if you experienced a crash that made you
depressed and suicidal, describe the experience in graphic detail, as if
you were writing a movie script —include where you were, what you were
doing, how you felt, what kinds of thoughts were running through your
mind, and how painful the experience was. This is a technique called "play-
ing the tape." When people crave crystal, their memory is often selective,
and they have euphoric recall, remembering the enjoyable parts of their
experiences. Even if they rationally understand the bad consequences,

that knowledge has little emotional impact on them — it is overshadowed
by the intense feelings of anticipating getting high again. By playing the
tape, you force yourself to recall the bad aspects of meth, with as much
personal and emotional meaning as you can make yourself remember.
The memories need to be vivid and powerful to balance out the effect of
euphoric recall. In addiction, the brain-reward circuit, which lies deep in
the primitive brain, compels you to use again, sending signals to the logical
cortex and tricking you to rationalize why you should use meth again. To
counter this, you need more than logical reasoning — try to activate other
deep brain structures, such as the amygdala, where emotional memories
are stored, to more fully recall the painful consequences of using meth.
Unfortunately, the amygdala is not as deep, primitive, or powerful as the
brain-reward circuit, so it is still a tough battle. However, its a battle that
you can win.
Question 3: What Are the Positive Things about Stopping

Crystal?
What improvements can you imagine in your life if you stopped using
crystal? Would you have more money to buy other things? Would your
personal relationships be any better? Would you function better at home,

work, or school? Would your health improve? How do the benefits of stop-
ping look next to the benefits of using?
If you are motivated to stop crystal, your answers to Question 3 can also
be a great motivating tool. Devastation and loss are often the strongest
motivators to stop drugs. But it is also important to have positive motiva-
tions. Together with the positive feelings that addicts associate with using
meth, there are also moments of clarity that many have, when they see
how far they've fallen, and they feel a hopelessness that they will never
be able to be the successful and functional people they once were. Then
the sadness of this realization becomes another reason to get high again.
Giving yourself positive goals will remind you that you don t have to be an
addict and that your life can be better. They can give you optimism that
will pull you out of hopelessness that would otherwise keep you trapped
in a cycle of using even more crystal.. Quitting is not just about avoiding
tragedy. It is also about recovering lost people and opportunities, getting
your life back, moving forward, and achieving even greater things in life.
When trying to stay sober is a struggle that makes you feel that life is empty
without crystal, use this list to remind yourself of the wonderful things that
can happen if you quit,
Question 4; What Are the Negative Things about Stopping

Crystal?
Are there any negative aspects to stopping crystal? If not, then you
should quit. Considering the risk of developing a powerfully destructive
addiction, if stopping were to cause no problems, why not stop before you
develop an addiction?.
fiowever, if you cannot think of any difficulties with stopping crystal but
you use fairly regularly, you may be one of those people who says, ''I can
stop anytime I want to, I just don't want to right now." See exercise 6-1 in
chapter 6 to see if you are one of these people.

Even for people who are not addicted, there are usually some negatives
associated with stopping crystal, such as not being able to bond with those
couple of friends who still use, or not feeling comfortable in some of the
places you go to socialize.
If you are a severe crystal addict, your answers to this question could
pose serious obstacles. For example, if your whole network of friends are
meth users, then trying to get away from them could leave you feeling
lonely and completely isolated. If using meth is now a requirement to
enjoy sex, then how can you imagine ever having sex after quitting? If
never addressed, obstacles such as these could frighten most people right
back into using.
Question 3 may seem as if it were meant to discourage you from stop-
ping crystal, but it is another important tool to help you manage your
recovery. In the past, doctors were afraid to ask their depressed patients if
they felt suicidal. They thought that asking about suicide might introduce
the idea and create suicidal thoughts. Could they cause their patients to
attempt suicide by mentioning it? Fortunately, psychiatrists found this was
not true. If a person does not want to kill himself, then uttering the word
"suicide" will not magically make him want to die. But if the doctor asks,
and the patient admits that indeed he has been feeling suicidal, then both
the patient and the doctor are now prepared to address the problem and
keep the patient safe. Similarly, mentioning the difficulties of stopping
crystal will not prevent you from quitting. If you try to stop using, then
you will face the same difficulties whether or not you've written them
down. However, if you forecast the difficulties that lie ahead and carefully
prepare yourself, then you will be much better equipped to deal with the
obstacles when they happen. If instead, you are completely unprepared
and a difficult situation catches you off guard, it is hard to think on your
feet because your addicted primitive brain is overwhelming you with sig-
nals telling you to use meth again; However, if you are prepared for the
situation, you can kick into autopilot, and even if it feels as if you are
reading lines from a script, you may be able to navigate your way out of a
potential relapse.
For example, if you predict that you will feel terribly bored if you stop
using, you should structure your schedule ahead of time to make sure
you are busy. Arrange your day with a balance of work or classes, exercise,
relaxation, and "working the program," meaning going to twelve-step meet-
ings or recovery groups. Keep yourself occupied and interested, but not
overloaded. Boredom and having nothing to do are common reasons that
people relapse especially early in recovery.
If you know that disappointment in sober sex will make you long for
crystal, you may have to take a break from sex entirely for a little while.
When you are further along in your sobriety, you can work on relearning
how to have sober sex.
If you know that you will feel lonely without your network of meth
buddies, then this would be a good time to reach out to family and sober
friends and try to rekindle old relationships that were casualties from your
drug addiction. Alternatively, it may be time to start cultivating new friend-
ships, ones that are based on something more meaningful to you than a
drug. Community activities and sports that you enjoy are good places
where you can meet new people with similar interests. Volunteering for a
cause important to you will give your life new purpose and meaning, and
you can meet new people who share your passion. If you can't find activi-
ties such as these in your community, twelve-step meetings, at CMA or

AA, are excellent places to meet people who you know share the same goal
as you of getting sober. They personally understand the struggles you are
going through, so from the outset, you know that you share some important
things with these people. Be creative and look around your community for
different opportunities to meet new people who have something in com-
mon with you and who don't do drugs.
If you have put sincere effort into completing the exercises as honestly
as you can, you should have a good idea of how crystal affects your life.
Hopefully this will clarify whether you must stop using crystal or if you
feel that you can continue to use with caution. If you are still unsure, go
back to chapter 6 and read it again with the information that you gained
from the Matrix Model, then see how things stack up.
PART
3
HOW CAN YOU HANDLE
CRYSTAL IN YOUR LIFE?
STRATEGY:
Learn the Basic Techniques for Stopping Crystal
Objectives:
• If you are not ready to stop, learn ways to handle
crystal safely while you monitor your use to see if you
are able to keep control.
• If you are ready to stop, learn some basic strategies
to break the cycle of use.
I
WHAT IF YOU USE CRYSTAL

AND YOU DON'T WANT TO STOP?
THIS BOOK IS written for people at any level

of crystal use, from the person who has
never tried it but is thinking about using to the hardcore addict who uses
every single day This chapter is specifically for those who have no desire
to stop using crystal —knowing that it is a drug with a dangerous poten-
tial, they want to learn more about it to minimize any possible harm.
Let me reemphasize that methamphetamine is extremely addictive:
the longer you use it, the more likely you will become an addict. Ideally,
you should avoid it completely Nonetheless, the truth is that not every-
one is ready or willing to stop, and many of those who continue to use
still care about their health and want to take precautions on their own
terms —perhaps this is why you picked up this book.
This chapter is written for those of you in this group, recognizing that
not wanting to stop crystal in no way makes you 'evil" or ''bad." You may
be sincerely committed to being as healthy as you can, but you need to
do it your own way, which may include not stopping drugs right now. If
you are going to use, here are some suggestions on how to keep yourself
as safe as possible.
In this chapter, you will learn specific strategies designed for the con-
tinuing user to monitor his or her meth use and to minimize any harm that
might result from the drug. This approach is called "harm reduction."
WHAT IS HARM REDUCTION?

Harm reduction is a drug-treatment philosophy that emphasizes the
importance of each individual's right to choose how to live. The guiding
principle is to identify each person's self-determined goals —not only regard-
ing drug use, but also a person's general life goals, such as relationships,
friendships, career, and finances. The form of harm reduction treatment
can var)^, tailoring itself to help each person achieve what he or she wants.
Focusing on people's personal goals helps to keep them motivated in the
treatment — it is really their personal quest for health, as they define it. In
this treatment model, a crystal user may strive for limiting crystal use to
rare, occasional partying, more frequent but regular and controlled use, or
even complete abstinence. All of these are considered acceptable treatment

goals, as long as the motivation is to keep oneself as healthy as possible.
If you had questions and concerns about your crystal use but you weren't
sure you had a problem, and you didn't want to stop partying, where would
you go? What if all meth programs welcomed only people who promised to
stop crystal immediately? Understandably, many people are offended when

abstinence-based programs are uninterested in their personal goals, which
may not include quitting meth. Instead, they perceive a blanket condem-
nation of all crystal users, which feels insulting and deters them from ever
turning to medical or addiction professionals in the future, even when they
know they need help. Harm-reduction programs are an important resource
for addicts; instead of alienating them from the medical system, it offers
them help in whatever way they are ready to accept.
You may want to educate yourself about crystal so that you can figure
out the safest way to party. If you're questioning the possibility that you
have an addiction, you may want an unbiased person to examine with you
how you've been using crystal to see if you are still managing it well or if
it has started to get out of control. You may want to know if you have any
medical or emotional problems due to your meth use, so you can decide
for yourself if you need to stop using. And you should be able to get these
services in a nonjudgmental setting that will not turn you away if you're
not quite ready to stop yet. The decision to stop needs to be yours, not
WHAT IF YOU USE CRYSTAL AND YOU DON'T WANT TO STOP I 89
someone else's. Harm-reduction programs were established to meet these

needs, to reach out and engage meth users who would otherwise turn their
backs on the medical and addiction communities.
When there are no harm-reduction services, some people who don't
really want to quit obtain the social and medical services they need by lying
about their drug use or their intentions to stop. But lying can be dangerous
because the treatment that they receive is based on false information. If
the treatment involves medication, then this can be particularly hazardous

because some medications can interact negatively with meth. For example,
the medication bupropion (brand name Wellbutrin) may help with depres-
l sion and cravings for crystal. However, taken together with crystal, it can
;
cause seizures.
';
Lying also sets up a poor relationship between the meth user and the
health-care provider because it lacks sincerity and trust. Ideally your health-
care provider should be your confidant and advocate, someone who will
not judge you but will try to give you the best advice.
Most continuing crystal users do not lie about their use. They simply
don't bother to seek any care. Some are blind to their health problems
because they are so caught up in meth use. However, many people who
fully realize they are medically ill have lost trust in the medical establish-
ment. Their wariness of the medical system may prevent them from getting
necessary treatment, even when they know they are seriously ill. Harm-
reduction programs try to prevent addicts from developing this attitude so
; that they are willing to get help when they eventually need it.
; Are there harm-reduction programs in your area? Currently most major

cities have some harm-reduction programs, which may vary from simple
drop-in information centers to harm-reduction counseling facilities. If
you do not live in one of these cities, contact an organization in a major

city closest to you; the staff may be able to direct you to services in your
area. Some may also be able to provide limited counseling over the tele-
phone, such as answering basic questions about crystal or providing crisis
management.
HOW CAN YOU USE CRYSTAL SAFELY?

Controlling crystal can be tricky because you are using a drug that
physiologically tries to hijack your brain and convince you to keep using it,
as well as to continue other behaviors you may associate with it, such as
sex, Internet hookups, or going out dancing. Before partying with crystal,
prepare yourself ahead of time to maximize your ability to stay within the
limits you set for yourseli when you are sober. If you are completely honest
with yourself, you know that you may not have complete control over your-
self when you are high, so before you start partying, set up some external
controls to keep things in check. A little planning can go a long way.
Decide How Much You Are Going to Use
Wherever you do crystal — at home, at a friend's place, at a sex
club, at a disco or circuit party —decide beforehand how much

you plan to do and how long you intend to party. While you are
sober, set a realistic and "healthy" limit, and make a decision to
stick to it. When you are tweaking (high on crystal), your per-
ception of how much is "healthy" will probably be much higher.
If you have ever found that doing more than a certain amount of
crystal made you feel anxious or paranoid, or if it s ever made you
hallucinate and hear, see, or feel things that were not there, set
your limit below this.
When setting your limit, don't forget to consider what the crash
will be like. Many people feel tired and blue after partying, but
if using more than a certain amount of crystal has made you
extremely depressed or even suicidal, set your limit below this.
If possible, buy your crystal before you go out, so you already have
the maximum amount you plan to use. When you leave home,
don't take your wallet, ATM cards, or credit cards. Carry an ID
for emergencies and enough cash to get you home in a cab. Better
yet, if you are going with a friend who is not drinking or using
drugs, he or she can drive you, and you can leave the cab fare
behind. Keep some emergency money on you, but bring as little

as possible to prevent the possibility of buying any more crystal.
If you are using at home, set aside the cash to buy the amount
you decided to use, and if possible, give your wallet, ATM card,
credit cards (you get the picture) to someone you trust to hold
on to them so that when you reach your limit, you won't be able
to buy any more, even if you want to. This may seem extreme,
but be honest with yourself: if you've ever done crystal, finished
your supply, and felt an uncontrollable compulsion to get more,

you understand that this is an important measure that may help
you stop when your tweaked mind says it still wants to party
If you are going out and will be with people you don't know, keep
your emergency money in a safe place (under the insole of your
shoe, in a hidden pocket, or elsewhere on your person).
Plan How Long You Will Party
Decide how long you plan to use crystal, and decide on a length
of time that is "healthy" and avoids negative consequences.

If you are a marathon partyer, is there a point in time after which
using meth changes from being fun and exciting to being anxiety-
provoking or scary? Is there a point after which you start to hear
voices? Set your time limit safely before this.
Usually, the longer people party, the harder they crash, and
the more depressed they become. Has crashing ever made you
unbearably depressed or suicidal? If you know this time point,
set your limit accordingly and stop using before this.
4 If you need to get to work on Monday, factor in recovery time,

and plan to stop early enough so that your crash does not spill
over into your next workday. If your crash lasts for twenty-four
hours, then make sure you finish partying early enough to give
yourself at least twenty-four hours to recover.
11 If you have HIV, which requires extremely tight adherence to
your medication schedule, plan on breaks to take your meds at
the right time, and if possible, set an alarm to remind yourself.

Make sure that your medications are safe to take with your crys-
tal: most HIV meds are safe, though some, such as the protease
inhibitor ritonovir (brand name Norvir), are not because they will
elevate your blood level of meth to toxic amounts. There are case
reports of people who died from extremely high blood levels of
methamphetamine when used in combination with certain HIV
medications. Check with your physician, or contact one of the
resources listed in the appendix to see how safely your medica-
tions mix with crystal. Many people assume it is not safe to take
any meds when they party. Some people know their meds are
safe but are too consumed by the drug high to take them. For
whatever reason, many people skip their meds completely when
they use meth. However, even brief drug holidays can allow HIV
to become resistant to the medication. If you find that when-
ever you are out using crystal you never take your HIV meds on
time, plan to finish partying before your next scheduled dose of
meds.
Observe These General Precautions While Using Crystal
When you are partying, you may become so engrossed in doing more
crystal and other activities that you forget to take the precautions you
would ordinarily to take good care of yourself. Here are some important
reminders:
If you are doing bumps or snorting lines, never share straws,

rolled-up dollar bills, keys, or ''bullets." Always use your own.
Snorting crystal causes damage to the mucous membranes in the
sinuses, and there can be microscopic bleeds. If this happens,

small amounts of blood, tiny enough to be invisible, can cover
these snorting tools. Sharing these snorting tools increases the
risk of catching or transmitting HIV, hepatitis B and C, and other
illnesses.
If you slam, never share needles and syringes. If you must share,
clean your needles and syringes with bleach and water before
the next user's turn, drawing the mixture through the needle and
into the syringe to make sure that the inside of the needle is fully
sterihzed. If using crystal makes you too impatient to take the
time to clean works properly, go to a needle exchange program

and make sure you have your own works.
Pace yourself. Decide how often you are going to do another
bump, smoke or shoot up. If you get the urge to do more, check
your watch to make sure you are not going too fast.
Take a break every hour to rest and hydrate. Crystal makes you
feel so energized that you don't detect your body's usual signals
telling you that you need rest or fluids. Drink liquids with sugar
and electrolytes, such as fruit juices or Gatorade, that will give
you much-needed calories. In addition, they will replace electro-
lytes, such as sodium, calcium, and potassium that you lose in
your sweat. These are very important for your heart to keep work-
ing properly Since crystal gives your heart a big workout, make
sure to provide the optimal conditions for it to work its best.
Fluids are also important for oral health. Dry mouth sets up
a comfortable environment for bacteria to grow, and cavities
and infections can occur much more easily. "Meth mouth"

results from long-term crystal use, characterized by softened,
misshapen, decayed teeth and bleeding, infected gums. If you
perform oral sex while high on crystal, any sores or bleeding
gums increase your risk of getting sexually transmitted diseases,
including HIV and hepatitis, (see Meth Mouth photo, page 34)
If you grind you teeth or clench your jaw when you are high, a
mouth guard isn't the sexiest thing to wear out to a party, so try
chewing sugar-free gum. This may provide a little more protec-
tive cushioning than grinding your teeth directly against each
other. Try chewing a gum such as Biotene, which promotes saliva
secretion and contains xylitol and other ingredients that have

some antimicrobial may help to fight HIV. If you
properties that
find that gum just makes you chew ferociously, try sucking on a
sugar-free candy to see if this moistens your mouth and keeps it
busy enough to stop grinding.
Take These Precautions if You Have Sex on Crystal
The intensity of sex is exponentially higher when using meth. For some,
this is one its most appealing draws. Studies looking at motivations of dif-
ferent types of users have found that gay men in particular sought more
intense sexual pleasure from crystal. In contrast, heterosexual men and
women reported other factors as more appealing. More recently, however,
studies have shown that heterosexual men and women experience pro-
found intensity when they have sex on meth. While sex may feel amazing,
it poses two significant problems: (1) the more you have sex on crystal,
the less appealing sober sex becomes, and eventually you may not be able
to have sex without the drug; and (2) on crystal, the drive to have sex
becomes so strong that important safer-sex precautions feel unimportant
and even bothersome. Keep the following in mind when planning your
next crystal-sex adventure:
Always remember to use latex condoms and lubricant.

Bring plenty of condoms with you because you will likely need
more than just one, and you should not assume that there will
always be condoms where you will be going. If you can't afford
them, go to a local Planned Parenthood or Lesbian Gay Bisexual

Transgender Community Center, where they are likely given out
for free.
When having sex, especially if you are continuing for a long time,
periodically check to make sure the condom has not come off or
broken. If you are the person who is being penetrated, periodi-

cally reach around and feel with your own hands whether your
partners condom is still intact. Do not depend on blind faith that
your partner is keeping tabs on the condom. Take active respon-
sibility for your own safety.
Use plenty of lube —enough so that things stay slippery. Mucous

membranes in the vagina, and more so in the rectum, are
delicate tissues, and it does not take much make them
to tear,
though crystal can mask much of the pain from injury. The fric-
tion of prolonged, marathon sex can easily cause these tissues

to bleed, so keep those surfaces slippery with lube. Remember,
there is no such thing as too much lube, so pour it on.
E Do not use lubricants or birth control gels and creams that con-
tain nonoxynol-9, a chemical used to kill sperm and prevent
pregnancy In test tubes, it was found to kill HIV, but in humans,
it caused irritation to mucous membranes that increased the risk
of transmitting HIV. Nonoxynol-9 is added to certain condoms,
lubricants, and vaginal gels and creams to help prevent pregnan-
cy However, to protect yourself from HIV and hepatitis B and C,
avoid using any products with nonoxynol-9, especially when you
do not know the health status of your sexual partner..
% Silicone-based lubricants are probably better than water-based
lubricants with latex condoms because they do not contain
water and never dry up, so they last longer than water-based
lubricants.
Never use oil-based lubricants, which can cause tears in
condoms.
Even if you are the one penetrating others, if you have sex with
someone with HIV, hepatitis, or any other STD, the germs are
now all over the condom, and the next person you penetrate will
be exposed to all those dangerous organisms. No matter what
your role is in sex, whether penetrating or receptive, change con-
doms with each partner.
If you see any blood, stop. You may not feel any pain, but if there
is any injury, your risk of getting a sexually transmitted disease
is high. If you are HIV-positive or have hepatitis, then there is
a very high chance you could give it to someone else. Whether

you are the person penetrating or being penetrated, periodically
check for blood.
When having oral sex, keep drinking liquids because the dry
mouth that meth causes makes your oral mucosa more suscep-
tible to cuts and abrasions, which can be entryways for STDs
such as HIV and hepatitis viruses. Meth mouth is already full
of potential entryways to catch diseases. Ideally, use a condom

when having oral sex. With more people educated about how
to prevent HIV transmission, the medical community has seen
more people who report getting HIV from oral sex, even if they
always used condoms for vaginal and anal intercourse. If you are
unwilling to have oral sex without a condom, (1) try to visually
inspect your partner's genitals for cuts or sores; (2) never let a
someone ejaculate into your mouth; and (3) periodically check

your mouth in the mirror because the high from meth and your
determination to have sex may make you oblivious to injuries
that can happen after hours of oral sex.
Anticipate and Manage the Crash
People have tried all sorts of remedies to help manage a crash, from
taking high doses of vitamins and antidepressants to taking herbal supple-
ments and drinking special teas. While many of these remedies are based
on some theoretical knowledge about meth, it is not possible to make
definitive suggestions because no rigorous studies have been found yet
that support any of these anticrash methods. For example, it had been
theorized that vitamin C, a powerful antioxidant, would protect the brain
from damage by free radicals released when taking Ecstasy However, one
animal study found that vitamin C actually increased brain damage. Other
studies have been inconsistent. And how do these animal studies translate
to humans? Nobody knows yet.
Natural remedies are just as much of an unknown as pharmaceuti-

cal treatments. Just because they are "natural," they are no less potent
or potentially harmful. Natural remedies work because their ingredients
are biologically active —meaning they cause biological changes, just like
pharmaceutically produced medicines. While moderate amounts of iron

and calcium in your diet are good for you, too much of them are toxic.
Other natural elements, such as arsenic, lead, and mercury, are frankly
dangerous and potentially deadly. Regarding herbs and plants, be wary.
Recall that hemlock and countless varieties of mushrooms can be deadly
Even kava kava, an herb and root commonly sold in health food stores for
anxiety, has been found to cause liver failure and death. Rather than look
for a magic pill, try to use these commonsense ways to soothe yourself to
manage your crash:
' Eat, especially carbohydrates, which will quickly replenish your

supply of needed calories. Despite the trend to eat proteins and
avoid carbs, if you are dehydrated after a long period of partying,
a high-protein load can damage your kidneys.

Drink plenty of fluids with electrolytes. If you are dehydrated,
your blood pressure will be low, you may feel more tired, and
your kidneys will not get enough blood flow to sustain them.
That can lead to kidney damage or even kidney failure. If you
have HIV, then your kidneys are already at increased risk of dis-
ease, so take precious care of them.
As you approach the time limit you set for yourself, start spacing
your meth doses further apart, or take smaller amounts. This may
be extremely difficult for some of you because you won't get as high,
which is what your body and mind will be begging for, but tapering
off more gradually will make the crash less sudden and severe.
Make sure you are somewhere comfortable when you are coming
down — ^your own home or a friend's place may be the best choices.
Keep your surroundings calm and minimize your exposure to
things that are anxiety-provoking or bothersome.

If you are having trouble settling down, keep yourself in a dark,
quiet place. Too much stimulation can keep your mind running
and not allow you to slow down. However, if a quiet place makes
you more aware of your restlessness, try watching TV and flip-
ping channels with the volume low to occupy your mind with the
television and your restlessness with the remote control, without
overstimulating yourself. Eventually you will start to wind down.

Try meditating by closing your eyes and visualizing pleasurable
scenes. Prepare a list beforehand of happy people, places, and
things. (Keep crystal-related people, places, and things ojf the
list, or you may find yourself back out there trying to get high
again!) Keep your mind focused on these things, which will help
keep your thoughts from sinking into darker places.
When tiredness finally sets in, let yourself relax, sleep, and rest
as much as you can.

Expect that you will feel mentally and physically tired and that
your mood may be erratic, irritable, or low. This is a natural part
of coming down, and unless you are suicidal or hallucinating, you

don't need to medicate these feelings —they will pass. Don't let
them become excuses for using more meth or other drugs.

If you are having sad, anxious, or angry thoughts, ask yourself
if this is you or the crash speaking. Remind yourself that when
coming down from crystal, everything can potentially be tinged
with a negative color. Remember that this will pass. Sometimes
simply knowing this can decrease some of the distress and help
you wait it out.
Do make any major life decisions while you are high or com-
not
ing down from crystal. Getting into arguments, ending relation-
ships with friends or partners, or deciding to quit a job or move
out of your home during a crash would be a big mistake. If you
are feeling upset about something or someone, tell yourself you
will deal with the problem after the crash is over. If the problem
is real, it will still be there when you are feeling better, and you
will be in better shape to make careful decisions.
If you are feeling extremely depressed and you have any suicidal
feelings, bring yourself to an emergency room or call 911. You

can also call a local suicide hotline, where someone may be able
to talk you through your depression or help you get more appro-
priate assistance. Meanwhile, keep reminding yourself that this
is a part of the crash and that suicidal feelings will pass, and it
is crucial that you keep yourself safe until they do. In this situa-
tion, medication can be very helpful, and in an ER, you can get
medication that is helpful but safe.
WHAT IF THESE TIPS DON'T WORK?

These suggestions should help you keep your crystal experience as
safe as possible. If you try them but you are unable to stick to the limits
that you set for yourself, or you continue to put your health, relationships,
or job at risk, then your meth use is out of your control. Speak with a harm-
reduction counselor to get other suggestions, and discuss whether now is
the time to think about stopping the drug, before it completely takes over
your life.
How much control do you have over crystal, and how much control does
it have over you? When you are sober and well over the effects of a crash,
make a list of things that you want in your life. Consider all areas: your gen-
eral emotional well-being, intimate relationships, your sex life, your family
and friends, school, your career, and whatever else is important to you. List
to what extent crystal has helped you in these areas, and how much it has
hurt. Be as honest as you can. Meth may help with many things on your
list, such as boosting your self-esteem, improving your mood, and helping
you to lose weight. But there are also a number of ways it may hurt you.
Review your lists: Are the benefits a fair trade for the problems? How
many negative effects are you willing to tolerate? How many occasions of
missing work are acceptable to you? How bad a crash is tolerable? How
much risk are you putting yourself at for HIV and hepatitis? After decid-
ing what is acceptable to you, don't just think about them, write them
down —because if you become addicted, the order of your priorities will
change: the pleasure you get from using will climb the charts to number
one, and you will forget which things in Hfe were most important to the
non-addicted you. At that point you will lose the ability to rationally dis-
cern whether you are addicted.

If you find that the balance of control has shifted, that crystal now has
more of a grip on you than you have on it, then the surest way to regain
power over your own life is to stop using —and that means completely If
you have reached this point, then read chapter 9 to learn about ways to
stop.
STOPPING CRYSTAL—
When You Feel That You Have Lost
Control of Your Life and You Want It Back
YOU FEEL that you have lost control over

IF
crystal, or if you haven't yet reached that
point but want to make sure you never get there, you need to stop using
completely. While this is my strongest recommendation to you, for you
to be truly successful at this, the final decision to stop must be yours
alone. Addiction is a powerful deep-brain phenomenon, and it will
require intense work from the nonaddicted parts of your brain to battle
and overcome the addiction. But if you are willing to make the effort,
then you can win.
Through studies on humans and animals, through what scientists have
learned about methamphetamine's physiological effects in the brain, and
through accounts of people using crystal, it is clear that this drug is power-
fully addictive. One of crystal's primary biological functions in the brain is
to make the animal exposed to it (in this case, that would be you) continue
to seek more. Crystal meth is an insidiously clever parasite whose primary
goal is to get you to take even more of it.
STOPPING CRYSTAL I 101
—
A good comparison is HIV an ingenious virus that hijacks a person's
immune system, the same system that a person uses to fight infections.
HIV uses the immune system to its own advantage, luring immune cells
to engulf it in its usual attempts to destroy invaders. However, HIV hides
inside immune cells and then takes control of them so they do all the work
of making more HIV and spreading it throughout the body.
Meth works almost identically It hijacks the user s brain and eventually
takes control, using it to control the mind and body to keep taking more
meth. Like HIV, meth lives and works in the part of your body that would
normally fight problematic behaviors, so it has weakened its most danger-
ous opponent. Repeated use of meth causes neuroadaptations —changes
in brain structure and chemistry — altering the user's brain function so that
judgment and decision making become weaker. As in the relationship of
immune cells and HIV, the brain becomes blind to the danger of ingesting
the drug (e.g., by going into denial, rationalizing, or making excuses for
why crystal is not so bad). Because the addict is less consciously aware of
the problem, crystal can take control. The brain's craving for it eventually
becomes compulsive and automatic, and the degree of its control over a
person's mind can be shocking. A person's life may be falling apart, with
loss of job or severe deterioration in health, but the altered brain still con-
vinces the addict to just keep on doing more crystal and that everything
is just fine.
This powerful and insidious mechanism of methamphetamine is the

reason that the only way to regain control or ensure that you will not lose
control is to prevent any exposure to crystal. Completely. Otherwise, with
the changes it slowly causes in the brain, you will lose the ability to dis-
tinguish between your own desires and those of the drug. During the act
of using meth, the compulsion to continue using is the most intense, so
stopping completely all at once will give you a better chance of success
than trying to decrease your use gradually. As an illustration, people com-
monly report that while using meth, even if they stop feeling pleasure and
have severe anxiety and paranoia, they still have a compulsion to use more,
feeling as if they have become automatons programmed with the single
purpose of getting more of the drug.
To avoid the trap, the most effective way to quit is to stop completely.
I
DETOXING
Note: There is currently no FDA-approved medication for the acute
treatment of methamphetamine withdrawal or the long-term treatment

of methamphetamine addiction. The medications discussed here are
based on current medical theories, results of recent medical investiga-
tions, and experiences with patients who agreed to use these medica-
tions in this way. I do not recommend that these medications be used
as described unless you discuss fully with a physician their risks and
benefits to you.
Unlike with alcohol and opiates, there is no universally accepted pro-

tocol for detoxing. This is unfortunate, because one of the greatest ob-
stacles to quitting meth is the fear of the impending crash. Physiologically,
crystal withdrawal is not dangerous-it won't kill you, as could happen in
alcohol withdrawal. You will not experience tremors, seizures, delirium

tremens with hallucinations, or death. However, crystal withdrawal can
be debilitating and emotionally painful, and if depression becomes severe
enough to make you suicidal, then indeed, quitting meth can be deadly.
A detoxification regimen would help a great number of people who are
having difficulty stopping because it would ease the pain and make the
process less frightening —one less excuse that the hijacked mind can use
to keep an addicted person from quitting.
The common experience of chronic users during a crash is extreme
fatigue and low mood. They have difficulty experiencing pleasure, can
feel depressed, and may even have suicidal thoughts. Appetite is greater,
and the need to sleep increases but it is irregular: often someone crashing
will sleep during the daytime, then have trouble sleeping at night. If you
have these problems, it can be extremely difficult to reestablish a healthy,
structured lifestyle. The frustration alone can spark a strong urge to start
using crystal again — for many people experiencing withdrawal, restarting

meth seems like the quickest and easiest way to feel better.
While there is no universally accepted way of detoxifying crystal users,
there are many different strategies that doctors can use to help ease you
through the experience. A good detox regimen should cover three basic
areas. It should:
1 . Decrease the intensity of the distress from a crash

2. Correct dysfunction or replenish levels of neurotransmitters in the
brain to ease possible depression, fatigue, and other functional
deficits resulting from the depletion of dopamine by crystal
3. Regulate sleep so that you fall sleep when you should (at night)
and stay awake when you should (during the day)
Ideally, a medication regimen with these components should be taken

while working with a substance abuse counselor who can support you
through the process and keep you motivated, While the medications ease
the discomfort of stopping meth, it is still a difficult process. Once the de-
tox is complete, continuing the motivation to stay clean is a much greater
challenge, one which a counselor can help you meet.
MEDICATIONS TO EASE PSYCHOLOGICAL DISTRESS
One of the most frightening experiences of crystal withdrawal and a

major deterrent to ending a crystal binge is the depression, which can take
various forms, such as dark mood, sadness, hopelessness, panic, and anxi-
ety. There are several medications that can provide quick and safe relief
when distress is unbearable. Unfortunately, the majority of these medica-

tions, called benzodiazepines, are potentially addictive and abusable.
Some commonly known medications in this class are lorazepam (Ativan),
clonazepam (Klonopin), diazepam (Valium), or long-acting alprazolam
(Xanax XR). The regular form of alprazolam should be avoided because
it has a particularly high addiction potential. Many addicts are already
familiar with these drugs, since they are often sold by dealers to help cut
the edge when meth causes too much anxiety or insomnia. In a detox,
they are prescribed in a very controlled manner to make sure they are used
therapeutically, instead of becoming another drug to abuse.
There are also other medications that are calming but do not carry the
potential for addiction. Clonidine (Catapres), most often used as a blood
pressure medication, works by blocking the release of adrenaline signals
from a nucleus in the brain that can cause anxiety and distress. Clonidine
is so effective that it is used in heroin detoxification, which can be excruci-
It has also been used as a nonaddictive treatment
ating. for the hyperactive
symptoms of attention-deficit/hyperactivity disorder.

Pregabalin (Lyrica) is a recently developed medication that blocks cal-

cium channels, which affect nerve transmission. It is currently used as
a medication for neuropathic pain (pain from nerve damage due to ill-
nesses such as diabetes, herpes zoster, or HIV). Preliminary studies show

that it can be as effective as robust doses of alprazolam and lorazepam in
reducing anxiety. Though is it chemically related to GABA, it does not

attach to GABA receptors or other receptors associated with addictive
drugs. However, if it is used regularly for a prolonged time, there can be
some withdrawal discomfort. Moreover, in two studies, a small number of
people reported experiencing mild euphoria from pregabalin, so the drug
may have some addictive potential. Nonetheless, preliminary data suggest
that it is much less addictive than the benzodiazepines, and at least two
early studies have shown it to be as effective as lorazepam and alprazolam
for treating anxiety.
MEDICATIONS FOR REVIVING THE BRAIN'S

NEUROTRANSMITTER SYSTEM
Crystal causes such a powerful release of dopamine in the brain that
the reserves are depleted and dopamine function in the brain is signifi-
cantly impaired, and it may take several days to weeks to restore enough
dopamine to improve mood, energy, memory, and clarity of thinking.
Therefore, medications that increase dopamine levels theoretically may

aid recovery. Medications such as bupropion and amantadine (Symmetrel)
are nonaddictive and can safely increase dopamine levels without any
risk of addiction. Early results from a study currently in progress show
that bupropion (Wellbutrin) is meth recovery and may even
helpful with
protect some brain cells from the damage caused by meth use. Earlier
fears that bupropion would increase the risk of seizure were not seen in
recent studies, and some of the subjects reported less of a dramatic high
from crystal, perhaps resulting in using less and shortening the length of
binges.
Another dopamine-like medication is ropinirole (Requip), which targets
dopamine receptors in a nonaddictive way. Unlike the other dopamine-

related medications, which often boost energy, many people find ropini-
role sedating. It may be helpful to take it in the evening when you want
to sleep, and also during the daytime if you have anxiety. By stimulating
dopamine receptors, it may satisfy brain cells that feel the lack of dopa-
mine. This use of ropinirole in this manner is theoretical and has not been
proven in any clinical studies at this time.
Stimulants, such as methylphenidate (Ritalin, Concerta, Focalin,

Metadate), pemoline (Cylert), or amphetamines (Adderall, Dexedrine)
should be avoided because their activity in the brain is similar to that of
methamphetamine, though at a much lower intensity. Stimulating the

same brain pathways can stir up some of the old feelings of cr^^stal use and
put you at serious risk of relapsing. One recent study found that methyl-
phenidate decreased cravings for crystal in some subjects. However, it is
not clear what this means in the long term. Will crystal addicts continue
to stay clean and sober, or are there other risks that methylphenidate may
cause? This is only the first study, and the validity and the interpretation
of the results are not yet clear. Before meth addicts rush to their doctors
asking for methylphenidate, here is a cautionary example to keep things in
perspective: Several years ago studies showed that gamma-hydroxybutyrate
(GHB), a popular club drug, was very effective in treating withdrawal and
decreasing cravings in alcoholics. Taken at face value, this study implies
that alcoholics should use GHB to stop drinking. Unfortunately, GHB has
also been found to be a much more addictive and dangerous drug than
alcohol, with many deaths related to its use.
The last medication I will discuss in this section is modafinil (Provigil).
Modafinil has been getting much attention in the medical literature

because of promising effects in early studies with cocaine addicts (who
may be neurochemically similar to crystal addicts). This medication seems
to increase cortical activity (activity on the surface of the brain), which is
normally low in heavy crystal users. It also improves energy and attention,
which is a benefit that many meth users miss during recovery, feeling flat
and tired without the drug. It may also help balance brain function that
would otherwise have led to cravings and relapse. However, modafinil
does not have significant dopamine activity, so it is considered to have low
addiction potential. While this seems like the perfect medicine to help
crystal addicts, there have been a handful of case reports of people feel-
ing some euphoria from modafinil, which reminded them of crystal, and
they experienced heightened cravings. This occurred with one of my own
patients, who started taking increasing doses of modafinil in an abusive
way. Fortunately, he was extremely motivated to stay clean and he never
relapsed to using crystal. Another patient who had a history of past drug
use but was not a crystal user tried modafinil and experienced severe LSD-
like visual hallucinations that were terrifying. The lesson is simple: be cau-
tious with any drug; even the most promising remedies have some risk.
THE IMPORTANCE OF NORMALIZING SLEEP

A MEDICATION TO help you sleep may seem unnecessary because most
people feel exhausted and sleepy when crashing from crystal. However, if
you look carefully at your sleep pattern, you may find that while it is easy to
doze off in the middle of the day, nighttime often brings frustrating insom-
nia and fitful sleep. Instead, strive to establish a sleep/wake schedule that
is well structured and leaves you feeling well rested. Structure is crucial
to recovery, and this includes the simple act of sleeping at night and wak-
ing up in the morning. Put yourself back on schedule with the rest of the
world so that you stay out of the ''drug addict" routine. This will help you
get back on your feet so that you can begin to work on important things
in life — your drug recovery program, going to work, and taking care of the
day-to-day business of life.
Trazodone is a powerfully sedating, nonaddictive antidepressant, which

in small doses can be an extremely effective sleep aid. Other sleep medica-
tions include antihistamines such as diphenhydramine (Benadryl), chlor-
pheniramine (Chlortrimeton), and hydroxazine (Atarax). Diphenhydramine
and chlorpheniramine are found in common over-the-counter sleep aids,
such as Sominex and Unisom. A recently developed medication called
ramelteon (Rozerem) stimulates melatonin receptors M] and M2, the
receptors in the hypothalamus that tell your brain when it is time to sleep.
It has a stronger effect than melatonin and is not addictive, but not all
people find it beneficial.

Avoid "benzo-like" medications, such as Ambien, Sonata, and Lunesta,
which target the same brain receptors as benzodiazepines, but in a slightly
different way. They are excellent for getting people to sleep, but they are
also easily abusable, causing psychotic symptoms, such as hallucinations,
which some people will try to experience recreationally In addition, when
taken in doses larger than the manufacturer's standard recommendation,
these medications have the same addictive potential as benzodiazepines.
Usually experienced drug users either know about the recreational effects,
STOPPING CRYSTAL I 10?
or they quickly find out. Therefore, the principle of ''if one works, two
should be better" definitely does not apply with these medications.
In addition to hallucinations, benzo-like medications have been associ-
ated with a number of unusual activities that seem out of the users con-
trol. This has been reported moreso for Zolpidem (Ambien). For example,
one woman woke up to find had she dismantled all her remote controls
and neatly organized the parts on the kitchen counter. In another example,
a man drove to his ex-girlfriend s home at four am and banged on the door
came and shook him awake. These people were completely
until the police
unaware of their actions, yet some of them ended up behind the wheel of
a car, driving in traffic! These are not fun experiences because the people
who have them can't remember them at all. However, they put themselves
(and others) at risk of serious harm. If you are trying to clean up and stay
sober, who knows where your unconscious mind could lead you in the
middle of the night? These medications are even more dangerous because
they are advertised as completely safe. They are not. Stay clear of them.
If you decide to try a detox regimen, you must do it under the supervi-
sion of a physician, ideally one with experience with addiction. When
discussing possible regimens, be sure you tell your doctor everything that
you take — recreational drugs, prescribed medications, over-the-counter
drugs, herbal supplements, and even vitamins. The last thing you want
when you are dealing with the challenge of quitting meth is an accidental
drug interaction that could have serious medical consequences.
HOW TO USE A DETOX PROTOCOL: WORKING WITH A DOCTOR

AND A TREATMENT CONTRACT
You MAY NEED ouc, two, or all three categories of medications to help ease
the discomfort of stopping crystal. Most of these drugs require prescrip-
tions from a physician, which may seem burdensome, but this is actually
a good thing because it ensures that the process is being monitored by a
health care professional. To detox, you must work with a physician. Ideally
this should be in conjunction with a drug counselor, who can support you
through the process of detoxing and coordinate other relapse-prevention
services to make a comprehensive and effective program that is tailored
to your specific needs.
Many experienced addicts know how to obtain the medications IVe
mentioned through drug dealers or by manipulating physicians, and the

temptation to do this so that you can orchestrate your own detox will be
strong. Instead, take yourself out of the drug-using world to accomplish
this. Put an end to the drug-using mind-set of trying to control everything,

and detox with the help of a physician. One of the hardest parts in this
process may be giving up control to someone else who will decide what
*'drugs" you put in your body. Letting go of control is extremely hard, but
admitting that you cant control everything is a fundamental principle that
will help you out of your addiction. Ask yourself this question: If you really
can control everything, then how did you get so addicted that you need to
be detoxed? It is time to hand the reins over to someone else.
GUIDELINES FOR WORKING WITH YOUR DOCTOR
Your physician should set up a 10-day detox schedule for you after
discussing which of the three categories of medications would be helpful

for you and which specific medications would be safe. In order for your
doctor to make these determinations, you must discuss everything that is
possibly relevant —medical conditions you have, what drugs you've been
using, and what medications you take.
Your doctor should give you prescriptions for enough medication to

last only 5 days, which requires you to check in with your doctor at short
intervals. Seeing your doctor frequently will keep up your motivation, put
a little extra pressure on you to stay sober, and if you are having any prob-
lems, they can be addressed quickly. Meeting frequently will also reassure
your physician that you have committed to getting off crystal and that this
is not a scam for get drugs, something that many physicians are wary of
and try hard to avoid. If your doctor sees that you are earnestly trying to
get better and are disciplined enough to stick to this structured treatment,
she will be much more open to trying a detox with you.

Day 6 is your second meeting with your doctor. That day, he should
collect urine for a drug test. It is another assurance that you are trying
your best and not just collecting scripts for meds to mix with other party
drugs. It is best when the doctors have on-site testing, so you can see the
results instantly and decide what to do if your urine tests positive. You both
discuss whether it feels safe to keep trying or if you need to be referred
to a drug treatment program that's better able to handle difficult addic-
tion cases. In addition, knowing that you are going to have a urine drug
test gives you even more incentive to try to stay clean. Shore up as many
reasons as you can to be mindful and keep away from crystal.
If things are going smoothly with the detox, your physician should give
you prescriptions to last you the remaining 5 days. Small prescriptions with
no refills decreases the temptation to use more than your schedule directs.
During a detox, you should see your doctor often. Picking up prescriptions
for the rest of the detox is a good incentive to continue your contact so that
someone is following your progress.
Your physician should draw up the following contract with you:
1. Your prescriptions are for 5-day supplies, no more and no less.
2. If you lose your medications, they fall down the sink, or you run
out of medication for any other reason before 5 days, I will not
provide you with any extras pills, prescriptions, or refills. The set
amount you get is a one-time deal. These medications are impor-

tant, so be careful and keep them safe.
3. Addiction is a chronic, relapsing, and remitting illness, meaning

that as an addict, you may relapse in the future. However, if you
require this kind of detox more than twice, this treatment is clearly
not effective, and you would require more intensive treatment

than this office can provide. In such a case, it would be clinically
inappropriate for me to continue to treat you in a way that has

proven to be ineffective, and I will not give you prescriptions for
any more detox medications. This in nonnegotiable Instead,

. I will
help you find a drug treatment program where you will receive
more intensive treatment for your addiction.
This contract is important for several reasons. First, your doctor needs
to feel that he or she can trust you. Most physicians are uneasy about
working with drug addiction, and many have been burned by patients ly-
ing to them in order to obtain controlled substances that they then abuse.
Most doctors have had patients say they *1ost their medications," or "ac-
cidentally dropped their meds down the sink," and they repeatedly ask
for more prescriptions. While this happens frequently with controlled
substances —medications that patients should be most careful with — for
some reason, nonaddictive medications, such as laxatives and antibiotics,

rarely get misplaced. Hence, most doctors are extremely wary of addicts
seeking drugs. After such experiences, many doctors may not be willing
even to consider trying a detox regimen. However, presenting your physi-
cian with this contract sets up parameters that can make your doctor feel
confident that you are making an honest and sincere plea for help and
that you are committing to work within a strict and safe plan that you
both agree upon.
Setting a Hmit on the number of times that you can request this detox
regimen prevents you from using it as regular way to end crystal binges,
making you feel more comfortable bingeing more often. Even if you do
not intend to keep bingeing, such a pattern can still develop. Making a
contract with your doctor creates a safety mechanism, so that if detoxing

and using your own resources to stop are not enough to quit meth, the
contract automatically directs you to more intensive care, which you will
likely need. Hardcore addicts will doctor-shop to get anticrash medications

from several different physicians, but if you truly want to stop, ( 1 ) sticking
with one doctor who knows you well, and (2) using the contract are the
best ways to protect yourself and to help your doctor to feel comfortable
enough to work with you. Show your doctor a copy of this chapter to fully
explain the reasoning behind the treatment. If your request seems logical
and medically sound, your doctor will be more likely to help you.
:
PART
0
NOW THAT YOU HAVE
STOPPEDp HOW DO YOU
STAY CLEAN?
Working on Keeping Crystal Out of Your Life
Ob j ectives
• Learn the concept of "relapse prevention" — not just
a treatment but a way of Living that will protect you
over your lifetinne.
• Learn what kind of "lifestyles" put you nnore at risk

for relapsing.
• Identify situations, people, places and things in your

life that may increase your chances of relapsing
• Learn lifestyle strategies that will improve your
quality of life as well as reduce your risk of relaps-
ing (e.g., how to say no, structure your time, reward
yourself, and develop techniques to help you get
through bouts of craving).
• Learn about the different kinds of addiction treat-
ments. Understand what they really are lare the

rumors true?), how they work, and what they offer,
so that you can choose the best fit for yourself.
RELAPSE PREVENTION
Working on Staying Clean
YOU HAVE decided to stop using crystal,

IF
you have successfully stopped, and you
want to keep it out of your life, then likely you have gone through some
deep soul-searching and difficult times to get this far. Congratulations!
But now the really hard work begins. The single act of quitting was a
monumental task, but it is only the beginning of a long road of maintain-
ing sobriety. Determining how to stay off meth and lead a crystal-free life
is a lifelong endeavor because addiction is not just psychological — it is
also physiological, meaning that it is a physical process in the brain that
occurs even if, intellectually and emotionally, you want to stay as far as
possible from drugs. But do not despair — things become much easier
with time.
The ambivalence and temptation to use crystal will always be a part of
you, to some extent. Imagine two parts of you —
one part wants to be drug
free and healthy, while the other part wants to use meth again. Think of
your mind as a corporation with two major shareholders competing with

each other to get enough shares to control the company — in your case, this
means making executive decisions about whether to use crystal. Relapse

prevention tries to keep the clean-and-sober shareholder in control, not
the addicted one who will eventually run the business into the ground.
As aggressive competitors, both shareholders relentlessly vie for control.
Therefore, you must be constantly vigilant for sneaky corporate takeovers

by your addicted side.
Though addiction has many psychological symptoms, it is as much

a medical illness as diabetes and high blood pressure. Looking at data
on patients with high blood pressure, diabetes, and drug addiction — the
statistics for how well people stick to treatment, how often they "relapse,"
or how often they have periods of worsening symptoms — it is difficult to
discern any significant differences. All three are biological processes. The
important take-home point is that like other chronic illnesses, addiction
requires ongoing monitoring and care. Even after you achieve sobriety, you
should not simply return to li\ang life the way you had been before. Just as
if you have been diagnosed with asthma, once you treat the acute illness,
you need to make lifestyle changes to minimize the risk of another asthma
attack. You must accept the fact that you need to treat and monitor your
health for the rest of your life.
Understanding addiction as a chronic disease helps recovered addicts

to keep aware of the constant threat of relapse in perspective, even after
several years of sobriety. Even after twenty years of sobriety, the potential
to fall back into full-blown out-of-control drug use is still there. The brain
circuits of addiction may be quiet, but they are still there, and they can be
activated and quickly return to a full relapse. There are countless stories
of alcoholics and drug addicts who stayed sober for decades, but once
they let their guard down and convinced themselves they were no longer
addicts, they found themseh es just as out of control with drugs as they
had been decades before.
A helpful model is to think of addiction as an escalator that is constantly
moving downward. You are standing in the middle of the addiction esca-
lator, and if you don't move your feet, the rolling staircase will take you
lower and lower, to the depths that addiction takes you. You have to walk
or even run up the steps to rise to safety. Even when you are higher on the
escalator, you must continue to climb just to stay in place and to prevent
the escalator from bringing you down again.
In this model, climbing represents the work you put into recovery.
RELAPSE PREVENTION I 115
Given time, effort, and the length of your sobriety, the escalator will slow
down, and it will feel less arduous to maintain your current level on the
escalator. Eventually it will be even easier to climb and to move higher up
in life, rather than just to stay in the same position. But never forget that
the escalator is always running. If you convince yourself the escalator has
stopped moving, you will stop climbing, meaning that you will forget about
your awareness and your recovery skills. And the escalator will gradually
bring you back down to the depths of your addiction.
The medical model emphasizes that much of the basis for addiction is
biological. Studies of the brains of chronic drug users show substantial

structural changes. Others studies, in humans and in animals, suggest that
these brain structures are responsible for controlling addictive behavior — if
they are damaged, the behavior is difficult to control, fôwever, the dif-
ference between addiction and other medical illness, such as high blood
pressure or asthma, is that the location of the malfunction is in the brain,
so the illness affects feelings and behavior. For this reason, it is easy to
understand why most people, including addicts themselves, see addiction
as a personality issue, and they attribute it to bad choices made under free
will, rather than to biological process. Society tends not to blame people
for having high blood pressure or diabetes, and there is little shame in
their seeking treatment for these illnesses. However, American culture

views addiction as a weakness of character. It blames the person for being
an addict, and the shame makes it even harder for the addict to admit to
having the illness and to seek treatment.

By clarifying its medical nature, I hope to destigmatize addiction,mak-
ing it easier for people to accept and treat. Under the medical model, a
slip or relapse in drug use is similar to an asthma flare-up: the person with
the illness is not *'bad"; in a chronic illness, we expect that a slip is bound
to happen at some time, though we work hard to minimize the possibil-
ity. Just like a patient with asthma, the addict should not focus on "being
a failure" for relapsing — this is demoralizing, and delays treatment and
recovery. Rather, a relapse or setback is an important time to investigate
what caused the flare-up and how treatment needs to be adjusted or inten-
sified to quickly get things back on track.
The medical model is not an excuse to let go and be apathetic about

addiction. It is not a reason to shrug your shoulders and say, "Well, there's
nothing I can do about it, it's inevitable, so I may as well keep using
crystal. " Quite the opposite. If a woman with diabetes found that her
blood sugar was too high, it would sound unwise, if not ridiculous if she
responded, *'So what's the point of this insulin? I may as well forget about
these meds and eat as much sugar as want because
I Til never get my sugar
under control!" During a disease flare-up, whether the illness is diabetes
or addiction, the affected person needs to tell his or her doctor what has
happened. Together they can consider what changes in lifestyle and treat-
ment are needed to get back on track.
WHAT IS "RELAPSE PREVENTION"?

Relapse prevention is an addiction treatment based on clinical prin-
ciples for treating alcoholics developed by G. Alan Marlatt, Ph.D., one of

the "founding fathers" of modern addiction treatment. The original model
has been adapted to many uses, from chemical to behavioral addictions.
The underlying idea behind relapse prevention looks at recovery as a con-

tinual learning process.
Older views of addiction were harsh and critical — sobriety was success,
and if you relapsed, you were a failure. You were either sober or you were
a hopeless addict. Without much room in between, many addicts felt that
if they slipped back into drug use, they were hopeless failures, and addic-
tion was their only lot in life. There was an unrealistic expectation that
sobriety was as simple as understanding that there was a problem —the
"epiphany" would magically take away the cravings and dangerous loss of
control. Needless to say, this perspective on addiction was discouraging
and demoralizing because the majority of addicts who try to stop eventually
slip or relapse a number of times before reaching any significant length

of successful sobriety. The older concept of addiction also made doctors
and other health care professionals reluctant to work with addicts because
addicts were almost all destined to be failures.
The modern concept of addiction does not consider a relapse to be a
failure. In fact, relapsing is almost inevitable in the process of recovery.
Many addicts use their frustration and feelings of hopeless failure as a
rationalization or excuse to continue using drugs —why bother quitting
if you will never succeed? Instead, falling down should motivate you to
get up, dust yourself off, and try harder. Keep trying and eventually it gets
RELAPSE PREVENTION I 11?
easier — that's how babies eventually learn to walk. If babies gave up after
their first few falls, we would all still be crawling.
BASIC PRINCIPLES OF RELAPSE PREVENTION
The basic goal of relapse prevention is simple: to prevent relapse. The

strategy is to identify the things in life that put you at risk and to figure
out ways to avoid them. This is best done with the assistance of someone
experienced, such as a counselor, a therapist, or a group, who can point
things out that you may not see. The addicted part of your mind works
insidiously and can distort your thinking and create blind spots, even when
your conscious motivation to stay sober is strong. Ideally, you should avoid
all things that pose a risk. However, in real life, it is not possible to avoid
all risks. Therefore, relapse prevention also includes working on how to
cope with risky situations effectively until you can get yourself to a safer
situation. The basic schema is a chain of three related phenomena that

can lead to drug use: situations, reactions, and coping skills, as illustrated
in figure 10-1.
ADAPTIVE
COPING
\
HIGH-RISK
SITUATIONS
REACTION
; MALADAPTIVE)
EMOTIONAL STATES
COPING „^
AVOID
HIGH-RISK
SITUATIONS
Figure 10-1 Relapse prevention theory.

The ways you live your life, or your emotional state, can bring you into a
situation that is a high risk for relapsing. When you find yourself in those
situations, how do you react? Right now your automatic reaction may be
to use crystal, but there are other, better ways of coping that can get you
through a high-risk situation without resorting drugs.
YOUR LIFESTYLE
How DO YOU live your life and what impact does that have on your emo-
tions? Is your job too pressured and stressful? Are you unemployed or
underemployed, feeling bored all day? Are you around people who use
drugs, and do you feel pressure to do the same in order to feel part of the
group? Are you unhappy or depressed and want to feel good again? Do
you have low self-esteem but are tr}dng to find ways to feel better about
yourself? Do you have HIV and feel like a prisoner of it, wishing you could
forget about HIV, even for a little while? Are you tense, irritable, and frus-
trated with your work, relationship, or family?
These are only a few of many important aspects of life that all people
should think about. Problematic lifestyles that cause negative feelings

often lead to relapse because addicts are accustomed to address negative
emotions with crystal rather than change the lifestyle..
Take inventory of your lifestyle —the way you lead your daily life, the
way you feel about yourself, and the way that you interact with other
people. Are any of these things situations in which you have used meth
to feel better?
See exercise 10-1, "Identifying Lifestyle or Emotional Issues," (page

130) to explore this further.
HIGH-RISK SITUATIONS
In Alcoholics Anonymous (AA), there is a well-known phrase, 'peo-

ple, places, and things." It is a reminder to think about which people,
places, and things, as well as situations and emotional states, are risky for
you so that you can steer clear of them. Having your crystal dealers tele-
phone number in your cell phone puts you at risk. The physical presence
of your dealer, as well as friends and acquaintances who use, put you at
risk. Simply seeing your dealer's number on your caller ID puts you at risk.
Places where you used to use crystal, such as your meth buddy's house,
discos, sex clubs, and circuit parties may put you at risk. Access to the
Internet in general may put you at risk.
Make a list of people, places, and things that are a high risk for you.
This is your personal list of high risks to avoid. In particular, when you are
newly sober and just beginning to develop better coping skills, you need
to stay as far from these risks as possible. Give yourself a breather from
those friends who use crystal. Stay away from clubs, sex parties, and cir-
cuit parties. Take a break from the Internet, where you may find yourself
searching sex sites and then run off to a crystal-sex hookup. Throw out
your dealer's telephone number and erase it from your speed diak If your
dealer sometimes calls you, tell him or her not to call you anymore, and if
your dealer persists, change your telephone number. This may seem like a
tremendous hassle, but the mere sound of your dealer's voice on the phone
can bring back a powerful rush of feelings that may overwhelm your best
intentions to quit. See exercise 10-2, "Identifying High-Risk Situations,"
(page 131) to explore this further.
There will likely be some items on your list of people, places, and things
that are unavoidable. Your dealer may be someone in your neighborhood
who passes you occasionally on the way to the store. You may need to
use the Internet regularly for work. Consider which items on your list are
unavoidable. If you are truly unable to get these things out of your life,
then you need to plan how to cope with them.

Here are some examples:
; If your computer is an essential part of your job and you depend

on e-mail, the Internet can be a looming temptation. If you don't
actually need the Internet for your job, uninstall the browser
from your computer (you can always reinstall it if you discover
that it is necessary). Getting rid of your Web access can block
those brief compulsions to "just take a peek at your old favorite "
sex sites, which could trigger old feelings and a strong desire to
get high. If your job does require Internet access, have someone
install a web filter (like "parental controls") on your computer
that restricts any sex-related sites. You should not install it your-
self because you can easily turn off the filter if your willpower
is weak. Ask your company information technology staff to do
this so that you don't accidentally damage the company network.

Simply explain that someone has been using your computer to
view adult sites, and you want to stop this from happening any
further.
If you can't completely avoid people you used to do crystal with
(friends, the local dealer, co-workers, your parents, your partner

or spouse, etc.), think of the situations in which you'll see them
and plan what you will say and do in each of them. If they start
talking about the last time they were hanging out using crys-
tal, the next big circuit party, or anything that may be a trigger,
think of standard responses you can fall back on, such as: ''Can
we talk about something else? ' Or politely change the topic to
something that's not a trigger for you, such as: "Hey, how's your
brother doing?" Practice the lines, even if they start to sound
like a script. Eventually you'll get used to saying them, and if you
always have the same response, eventually your friends will learn
that you don't respond to conversations about their drug use or
other drug-related topics. mouse keeps pushing a
If a lever for
food but nothing ever comes out, eventually the mouse will give
up and stop pressing the lever.
If the people you can't avoid ask you directly to use crystal with
them or invite you to a place where you know people will be
using crystal, say "No thanks." Refusal skills are essential —you
are firmly saying no to the people who are tempting you, but you
are also firmly saying no to the addict part of you that always
wants to take control. See the section called "Refusal Strategies"
(page 121) for a detailed discussion of this topic.
If the people you can't avoid are people who live with you, such
as a parent, a spouse, or a partner, and they refuse to stop using
crystal, it's time to change living arrangements. One way or

another, you need to keep your home a clean and safe place.
M If you used to do crystal in your bedroom, what do you do? Everv'
aspect of the room — the look, the smell, the place you sat when
you smoked or the table you stood over when you snorted lines,
will trigger memories and feelings that can powerfully pull you
back to crystal. Short of moving to a new home, you will have
to make some changes. Paint the walls a different color. Get dif-
ferent color bed sheets. Rearrange the furniture, and if possible,

replace some things, such as the table you used to snort lines
on. It's the same room, but when you sit in your chair from a
different angle, and you see walls in a different-colored and with
different pictures, your brain is less likely to feel the same cues it
did when you were using crystal, and it will be less of a reminder
of those times. Think of Pavlov's dog, which salivated every time
he heard a bell because the sound of the bell was paired with
receiving a steak. In this case, the bedroom is the bell, and meth
is the steak that was paired with it. If you can't get rid of the
bell, at least change the sound enough so it stops making you
salivate.
There are many people, places, and things that can increase your risk
of relapsing. However, as you can see, there are as many ways to deal with
them if you aren't able to completely avoid them. The best strategy is to
plan ahead so you can be prepared. Learn the danger zones you can avoid,
and for the unavoidable, create a specific plan for how you will deal with
each situation —even if you don't use that exact plan in the real situation,
the planning process is empowering, and you are more psychologically

prepared when you face the trigger. If you are caught totally off-guard
in a high-risk situation, the urge to use may be so strong that you can't
think well on your feet. Or more likely, the desire to use may become so
strong that you will not want to think. If you are prepared, you won't have
to think much because you'll already know what to do. You just need the
inner strength to do it.
REFUSAL STRATEGIES
"Just Say No." The catchphrase from Nancy Reagan's well-intentioned
antidrug campaign sounds oversimplified, underestimating the power of
addiction. However, combined with other strategies of relapse prevention,
the ability to say no is extremely powerful. And difficult. This is why it is
important to ^practice refusing. When someone suddenly offers you meth,

there's very little time to think of what to say. Intellectually, you know you
should say no, but will you be able to? If you have practiced the words,
they will be easier to say. If you have practiced them until they've become
" " "
automatic, they will be even easier to say, regardless of whether you sin-
cerely mean them at the time. Early in recovery, you will be struggling
against a powerful temptation to say yes. But that is irrelevant here. Your
single goal is to get away from this powerful danger. Just say no. Avoid any
interaction in which the powerful cue of meth that is being dangled in your
face could possibly overpower any rational thought. You may continue to
struggle against the wish to say yes, but without the crystal within reach,
your logical side will have a better chance of staying in control.
Think of a common scenario in which someone offers you crystal, such
as passing old drug pals on the street, or at the beginning of a hookup with
someone you meet online. Think about how you want to come across to
other people and what action would effectively end this dangerous situa-
tion. You want to feel and appear firm and unwavering, not indecisive and
unsure. A dealer or other crystal users can sense ambivalence, and they
know how to target your vulnerabilities. Don't be fooled by their generos-
ity. Whether they are dealers or friends, they have selfish reasons to get
you to use: The dealer obviously wants to make money Even the generous
freebie that gets tossed your way is just a ploy to get you hooked and back
to being a regular paying customer. Other users want you to join in because
it makes them feel less guilty about their own use
— "Crystal can't be that
bad if someone else is doing it, too, right?" Disregard whatever they tell
you, and focus on your primary objective — to be clean and healthy Tell
them no. State it clearly and succinctly, without reservation.
Some possible ways to refuse are:
W **No, thanks, I'm taking a break from partying."

"No. I realized that it's not good for me, and I'm trying to stop."
'*No. Crystal's become such a big problem everywhere you look,
and I've decided I don't want anything to do with it anymore."

"No. Crystal is really affecting my health, and I don't want to do
it anymore.
"No. I realized that I have a problem with crystal, and I decided
that I'm going to stop.
. "No. 1 realized that I have a problem with crystal, and I decided
that I'm going to stop. As my friends, I need your help with this,
so please don't talk to me about crystal anymore.

W "No. I have a problem with crystal, and I decided that I'm going
to stop. I don't want you to sell it to me, and I don't even want
you to talk to me about crystal again."
. Or simply, "No, thanks."
Make eye contact when you say no, which shows sincerity and gives a
nonverbal signal that you do not welcome a challenge to this statement.
Never use expressions such as "I think" or "It seems like"; leave no room
for possibility in your refusal. Keep the interaction brief. If you are in a
situation where you have to talk to these people, change the subject com-
pletely and don't take the bait of being drawn back to it. Be a wall. They
will keep trying to steer the conversation toward meth to undermine your
determination. If they still do not respect your clearly stated refusal, it is
clear how little regard they have for you. If you are surrounded by people
who have no regard for you, if they are relentlessly pushing you toward
danger, how does that picture look to you? Give yourself the respect you
deserve and remove yourself from harm's way — leave.
Once you've written out your script, practice it with someone in a role-
play. At first it may feel silly and you may joke about it. That is fine —enjoy
yourself! Just remember that the reason you are doing it is serious — to
save your life. Practice it over and over until it rolls off your tongue natu-
rally and you hear yourself saying the words with natural confidence. In
a real situation, you are not just saying these words to your dealer or your
friend —you are also reminding yourself of your strong conviction. In a
high-risk situation where your craving may be piqued, hearing your own
voice state definitively that you will not use will remind you that the strong
and healthy part of you is in control. Every time you say it, it emphasizes
your determination to recover.
STRUCTURE YOUR TIME

When you are first stopping crystal use, keep yourself busy Put in writ-
ing a detailed schedule, not an amorphous list of possible activities you
keep in your head, so that you have a committed activity or meeting with
sober people scheduled for every hour of the entire day. This includes
scheduling rest time, but with sober friends. Make a schedule for at
least one whole week after quitting, and be especially careful to be safely
occupied during the times you used to get high, such as on the weekends
or after work. Make the activities a mixture of productive work and fun.
This will keep your mind occupied when, left to its own devices, it would
gravitate toward thoughts ahout crystal. Do something interesting with
friends rather than stay at home feeling bored, lonely, and sorry for your-
self because you otherwise would be out getting high on meth during that
time. Other activities may not feel as satisfying at first, and that's alright.
However, they will help get you through the rough initial period.
Even after you have made it through the early stages of stopping crystal,
sticking to a structured schedule is a basic principle of relapse prevention.
Structure prevents boredom, a big trigger for drug use; it keeps your mind
occupied when all it wants to think about is crystal; and it helps you feel
productive, and positive about yourself. A structured life is the opposite
of the addict life, which is organized on whim and the need for immediate
gratification. So structure takes you into a healthier lifestyle and gives you
a balanced framework that encourages moderation and discipline.
To fill your schedule, think of activities that take you out of the house,
such as playing a sport or taking a class in something that has always
interested you. Think of people with whom you can spend time in healthy
and enjoyable ways. Keep your schedule organized and realistic. Include
time for work, exercise, rest, and most important, healthy fun. Balance is
the key to making your structure work — it prevents you from burning out.
With the correct balance, structure will eventually feels stabilizing and
comfortable, not restraining.
REWARD YOURSELF
Calculate how much money you used to spend on crystal. When
totaled up, this can be a shocking amount. Calculate how much money
you would have spent on meth in a single month. Make a list of ten differ-
ent things that you could buy with that amount of money. Pick one of those
items on the list as a reward you promise yourself at the end of the month
if you stay clean. To make sure this stays an active motivator during the
course of the month, set weekly goals for yourself. For example, suppose
you used to spend $400 per month on crystal, or approximately $100 per
week. At the end of each week that you stick to your sobriety, take $100
and buy a gift card at a store that sells the item that you want to buy. Put
the gift cards somewhere visible so you can remind yourself how well you
are doing and what kind of reward you are building up to. At the end of one
month, you will have $400 in gift cards to purchase the item you want.
The rationale for buying gift cards each week is that you need to have
frequent small rewards throughout the month to keep you motivated, and
by putting the cash into gift cards, you will not be able to use the money
to buy crystal if you are suddenly hit with a strong craving. Many places,
such as Starbucks, Sears, Circuit City major clothing stores, many restau-
rants, and even nail salons and spas, offer gift cards. Many gift cards can
be purchased online, so they are convenient and easy to get.
The concept of a reward incentive may sound childish, like giving a

child candy for behaving well. But this isprobably why it works —
it appeals
to the more primitive part of the brain and doesn't require logic or higher
brain processing. Research has repeatedly shown that this technique, called
contingency management, is one of the most successful interventions to
keep addicts clean. A recent study by the National Institute on Drug Abuse
found that almost 50 percent of people who were rewarded for drug-free
urine fondly called "peeing for prizes, were able to complete a twelve-week
"
treatment program, compared to 35 percent of people who were given only

verbal praise. Offering rewards to addicts increased the likelihood that they
would be sober at any one time, it quadrupled their chances of remaining
completely drug-free for the entire twelve weeks of the treatment, and it
increased the likelihood that the person would stick with treatment, even
if they slipped.
Positron emission tomography (PET) scan shows images of how the
brain reacts during different thinking tasks. A study of what parts of the
brain are active during states of happiness looked at the brain while sub-
jects focused on different "happy" things. Warm and positive memories
about family and childhood activated particular parts of the brain, while
money and material goods activated different brain centers —the same
areas of the brain activated by cocaine and methamphetamine. In addition
to the psychological effects of contingency management, there seems to
be a biological basis for the efficacy of rewards —they may stimulate brain
regions that are impaired and less active after chronic drug use. Gently
stimulating these areas with rewards may increase chronically low dopa-
mine activity satisfying a biological need, and thereby stave off further
craving and relapse.
HOW TO TOLERATE CRAVINGS

"Craving" refers to both the emotional and physical feelings of want-
ing to use something. In this book craving refers specifically to crystal,
though people can crave other drugs, foods, activities —almost anything.
The implication of the word craving is that your desire exists despite the
knowledge that you cannot have the thing you want. Cravings vary from
mild, passing thoughts about using to intense and overwhelming feelings
with bodily reactions, such as tingling skin, rumbling in the stomach,
intestinal cramps, and even diarrhea. Cravings can feel irresistible, as if
you are compelled to act on them. When craving is intense, you may feel
that you have no option, that you must use. But no matter how urgent the
feeling, if you don't use crystal, you will still be alive the next day. And
you'll be much healthier.
This section gives a few suggestions for handling cravings. Thoughts

about crystal can cause physiological reactions in your body that occur in
conjunction with other types of anxiety. Therefore, some relaxation tech-
niques are often helpful.
Deep Breathing and Muscle Relaxation Exercise
The first time you do this exercise, have a friend read you the instruc-
tions as you do the steps. Choose a friend with a calm, relaxing voice w^ho
can slowly lead you through each step. After one or two times, you will be
able to do this exercise alone from memory. However, if hearing another
person giving you soothing instructions feels more effective, have your
friend read the instructions on a tape that you can play whenever you do the
exercise. Hearing your friend's voice may also be a nice reminder that you
are not alone, and that other people care about you and your sobriety
INSTRUCTIONS:
Find a comfortable and quiet place where you can lie down. Lie on your
back, close your eyes, and place your hands at your side. Take a slow, deep
breath through your mouth over 5 seconds, then exhale slowly through
your nose over 5 seconds. Take 3 deep breaths like this, slowly inhaling and
exhaling.
.
RELAPSE PREVENTION I 12?
Continue to breathe this way throughout the entire exercise. With time
it will feel natural, and you won't even have to think about it.
Tighten your fists, squeezing them as hard as you can. Keep holding
them tightly for 5 seconds . . . and relax. When you unclench your fists,
focus on the sensation of the blood rushing back into them and feel the
tension melt away from your hands.

Next, squeeze your fists in the same way, and press your arms against
your sides, pushing them against your body as hard as you can. Hold the
position for 5 seconds . . . and relax, again feeling the blood rushing back
into your arms and hands as you release the tension. Take a moment for
another slow breath in and out.

Now, curl your toes and clench them tightly, together with your fists
and your arms. Tighten and hold them all for 5 seconds . . . and relax. Take
another slow breath in and out.
Press your knees together, pushing as hard as you can. Now you are
squeezing your toes, your knees, your fists, and your arms. Hold the posi-
tion for 5 seconds . . . and relax. Take another slow breath in and out.
Now, lift your shoulders up toward your head and tense up your neck
(skip this step if you have any history of neck injuiy or pain), tensing up
every part of your body and hold the position for 5 seconds —focus your
mind on the tension in your fists, your arms, your toes, your knees, and
your shoulders. Then relax. Take another slow breath in and out.
Scrunch up your face, tightening your eyes and your mouth as hard as
you can. You should be tensing every possible muscle in your body now,
squeezing them as hard as you can. Hold for 5 seconds . . . and relax.
Feel the waves of blood flowing back into all your body parts. Focus on
the sensations and try to be aware of every part of your body.
Now, imagine that your head, shoulders, arms, and legs are made of lead
and are extremely heavy. Feel them sinking into the floor or the cushions
under you. Let your shoulders drop as your feel their weight, and relax
them as you let them sink into the cushions.
Slowly take 5 more deep breaths. Count backward slowly from 10 to 1
When you reach 1, slowly open your eyes.

The Wave
This exercise deals with urges and cravings by using a relaxation and
visualization technique. Sit in a comfortable chair and close your eyes. Take
3 slow, deep breaths, just as you did in the muscle relaxation exercise. Now
imagine yourself standing on a beach ankle-deep in the water. Visualize
your cravings as a wave that is building up to a crest. The wave may be very
high, depending on the intensity of your cravings. Watch the wave come
closer, but stay where you are. Do not run away from it. In fact, imagine
yourself sitting down in the shallow edge of the water, waiting for the wave
to come. When it arrives, it may buffet you with a strong force at first, but
sitting in the sand, you are stable and are able to hold your ground. The
wave keeps moving and you can feel it wash over your body Gradually it
passes over you and runs past you, disappearing into foam on the beach.
Then watch it gradually recede into the ocean, taking your cravings out to
sea. Take 3 more deep breaths and slowly open your eyes.
This technique is a relaxation exercise that helps you to conceptualize
your physical and psychological cravings in a visual metaphor, the wave.

It reminds you that if you stay where you are and just do nothing, the
urge will eventually pass. When you have a craving, despite the urgency
and desperation you feel, nothing will happen if you do not use. You have
survived cravings in the past, and you will sur\ave even more in the future.
Each time you successfully let a craving pass, the tension will become less
intense and the next wave will seem smaller. This is a convenient exer-
cise because it is simple and it can be done whenever you feel a craving,
whether you are at home, at work, or sitting on a bus or in the subway.
DEVISING NEW WAYS TO COPE WITH BAD FEELINGS

For addicts, drugs have become the major way of coping with negative
emotions. Even if you do not have immediate access to crystal, just the
knowledge that you can get high when you get home may comfort you in a
tough situation. Giving up drugs completely takes away your most familiar
and comfortable way to ward off bad feelings. Before using drugs, you had
other ways of dealing with problems, but after a long time of depending on
crystal, you may have forgotten them and will need to relearn them.
If you feel upset, frustrated, sad, or angry, what are some ways that you
can deal with your feelings without resorting to crystal or other drugs?
Think of answers to this question when your mood is good and you are
thinking rationally because when unhappiness suddenly hits you, you will
be in no frame of mind to think of good solutions. The more upset you

are, the more desperately you will grasp for any way to feel better. Since
the most familiar solution to your problems may be crystal, if you have
not prepared any alternative plan of action, doing crystal may be the only
solution in sight.
Think about what you can do immediately when you get upset. What
are things that can distract yourself from unpleasant feelings, help you to
relax, or help you blow off some steam? One technique is to immediately
stop what you are doing and take ten deep breaths while repeating a calm-
ing phrase, such as "Everything is all right," or "I am still a good person."
Other examples include taking a slow walk around the block to clear your
head, doing some exercise like jogging, calling a friend or twelve-step spon-
sor, taking a long, hot bath, trying one of your relaxation exercises, going to
a yoga class, or attending the nearest twelve-step meeting. Make a list with
several techniques that you know can soothe you, so that you have a long
list of options other than drugs that are possible in any situation.
Also consider intermediate interventions that can help you cope. This
includes making plans during the week that you can look forward to, so
that despite whatever unpleasant event you are going through now, you
can expect relief sometime soon. Using intermediate interventions is a way
to practice tolerating frustration for short periods of time. You will gradu-
ally be able to tolerate longer periods of time without needing immediate
gratification and instant relief. Examples include getting regular massages
each week, watching a movie or a show, seeing an exhibit at the local
museum, or having dinner at your favorite restaurant. Choose realistic
activities that you enjoy. Anticipating the enjoyment later in the week can
pull you through a difficult situation in the present. When you finally make
it to your planned activity, it also feels Hke a well-deserved reward, which
reinforces the success of your new coping skill.
Finally, set up some long-term goals, such as improving your health,

furthering your education, moving along in your career, and improving your
relationships. Don't pressure yourself too much, but focus your eyes on the
horizon. These goals will remind you why it is important not to relapse and
will keep your motivation strong. When you are stuck in a bad situation.
contemplating your long-term goals will pull you out of your current emo-
tional chaos and give you a broader perspective on your own life. Despite
whatever unpleasant thing is happening to you right now, step back and
see your life moving in a good direction as you keep working toward your
long-term goals. Think of the old sailor's remedy for seasickness — if you
keep your sight fixed on the steady horizon in the distance, you will not
feel so sick from the rocking of the boat right under your feet.
See exercise 10-3, "Coping Skills," (page 132) to make a list of activities
tailored to your personality and needs.
EXERCISE 10-1 IDEETIFYINa LIFESTYLE \
OR EMOTIONAL ISSUES i
WHAT aspects of your life make you automatically think of using
crystal? I
Think about all areas of your life (general emotional state, job, rela-
tionships, sex, family, medical problems, etc.).

EXERCISE 10-2 IDENTIFYING HKJH-RISK SITUATIONS
MAKE a list of people, places, and things that remind you of using
crystal:
People:
ii
Things: '{
I
EXERCISE 10-3 COPINa SKILLS
Use to:
' ' -
i •
Develop more adaptive immediate self-soothing techniques

k> Develop & strengthen your ability to tolerate frustration over time
(intermediate and long-term strategies)
m Remind yourself of long-term goals to put immediate problems
into perspective and to build your self-esteem
List five things you can do immediately (today) to make yourself feel bet-
ter (e.g., hot shower, take a walk in the park):
1.
2.
3.
4.
5.
List five things you can do this week to make yourself feel better (e.g., go
to a museum, get a massage):
1.
List five things you can do in the future that will make your life more
satisfying (e.g., improve your relationships, go back to school, advance
in your career, cut down the stressful things in your life):
1.
2.
3.
4.
5.
—
11
THINGS YOU CAN DO TO BEAT

CRYSTAL ADDICTION:
Some Specific Strategies
CHAPTER 10 DISCUSSED the general prin-
ciples of relapse prevention. This chapter
will look at specific activities that can help you move forward along the
road to a drug-free life. All the activities discussed follow the guiding
principles of relapse prevention: understanding and avoiding risky situa-
tions and learning to cope with the unavoidable.
TALK ABOUT IT
Talk with people about your experiences with crystal. Find a person
that you trust, someone with whom you feel safe sharing this information.
Talking about drugs with sober friends and family may not be comfortable
if it were easy, you would have done it already. Possible people include your
partner or spouse; a family member;who knows you well, even if
a friend
you have not spoken with that friend for a long while. Whoever you chose,
be sure the person does not use drugs. Former drug users who are in suc-
cessful recovery can be extremely helpful because they have been in your
THINGS YOU CAN DO TO BEAT CRYSTAL ADDICTION I 135
shoes —they can understand the highs and the lows you Ve felt on meth, as
well as the difficulty of your current struggle. People who have never tried
crystal are also helpful, but they must be open-minded, without automati-
cally condemning you for your past drug use. They can listen to your story
with a thoughtful ear, offer you compassion and support, and remind you
what your own life was like before crystal, which may seem like a com-
pletely different person s life. The process of explaining your drug history
and your feelings to someone drug-naive, trying to get them to understand
what it was like, may actually help you clarify your own thoughts. Whoever
you choose — a former meth user, someone in recovery from other drugs,
or someone who's never tried drugs — will have something to offer if you
open up to them. The more people you can talk with, the better. When
temptations are strong, they can support you through difficult times, when
you might otherwise be led to relapse.
Open yourself up and be honest. Whoever you speak with needs to hear
everything, both the good and the bad experiences: your feelings, desires,
and fears of using crystal, as well as your feelings, desires, and fears of stop-
ping. To benefit from talking with others, you should end the conversation
feeling understood. While it is rare to find someone who can understand
you completely, if you feel the other person can't see the picture at all, find
someone else. Do not let the frustration of feeling misunderstood grow into
a rationalization to use again. On the other hand, if people respond with
words that don't sit quite right with you, before disagreeing or trying to
correct them, try to keep your ears open and examine what they are saying.
This follows the AA adage "Take the cotton out of your ears and put it in
your mouth." Before you say anything, take a minute to ponder their words,
consider if this may have anything that
completely different point of view
might be relevant to you, and then give your response. You may be so used
to your old view of your drug use and sobriety that new ideas that initially
sound completely off the mark may actually be right on target.

Sharing the fact that you are addicted can lift a tremendous burden off
your shoulders. Holding such a big secret creates tremendous pressure,

and the tension creates a wall that separates you from your family and
friends. Opening up to people about your addiction allows you to con-
nect with them in an honest way. Lying and hiding are survival skills in
the drug-using world. In time, they weave their way into an addict's life
so completely that, after a while, they become a part of every interaction.

even when there is no reason to hide the truth. At that point, the addict
may be unable to connect with anyone in an honest and sincere way.
An interesting note to add here is that while crystal makes your brain
think you are happy, psychologists have found that one of the strongest
determinants of "happiness" is meaningful interpersonal connections,
which are usually lost when people become severely addicted to crystal. So
reestabhsh those connections, and don't listen to the addicted brain telling
you that you'll never feel happy without crystal. Staying clean and improving
interpersonal connections may be the best way to recover true happiness.
By talking about your addiction to others, you are constantly reminding

yourself. The addicted part of you wants to deny any problem with crys-
tal, even if it has completely destroyed your life, and that desire to deny
will always be lurking, waiting for you to believe it. The moment you let
your guard down, the lurking addict takes the opportunity to trick you,
concocting an innocent excuse to try crystal again: "It's been four years
without cr}^stal, and I can't remember the last time I even thought about
it. Everyone is going to be partying tonight, so what's the harm in doing
just one bump? After four years, I should be fine."
Sharing the story of your addiction with others makes it real. It is like
the old question, "If a tree falls in the forest and no one is there to hear it,
does it make a sound?" Make sure someone else hears your admission. The
tree fell, and you both heard it, so you know it made a sound —you both
know that you have an addiction, and it is real. Down the road, when you
may feel weak, it will be harder to deny the past so that you can rationalize
using again. This is another step toward successful recovery.
If you still can't talk about your addiction with anybody, ask yourself why
not. The addict side of you may be rationalizing and making any possible
excuse to avoid things that would help you quit. This is a cardinal sign of
addiction: despite knowing you need to stop using, you can't control the
part of your brain that still wants to use — rather, that part controls you.
Fighting that part of your brain is difficult, so enlist the help of others. This
is another important reason that talking with others will help you overcome
the addictive forces in your mind.
Research shows that the more social support one has —the more friends
and family who are aware and supportive of the recovery —the better the
chances of becoming controlling the addiction. There are many possible
reasons for this, though nobody knows the definitively Whatever the
reason, the numbers speak for themselves. Involving friends and family in
your recovery helps — a lot.
INDIVIDUAL COUNSELING
In addition to talking with friends and family, working with a profes-

sional who specializes in addiction is a crux of early treatment. In the past,
"drug treatment" consisted of an addict simply listening to admonitions or

instructions from a health care provider. This was a passive process. The
addict was a "patient" who expected to be cured on hearing the magical
words from an insightful healer. However, nothing magical about the doc-
tor elicits a cure, and a passive attitude will doom an addict to relapse. This
antiquated method of addiction treatment needed a complete overhaul.
Recovery is an active process that requires hard work. You and your
counselor should work together as a team toward a goal that you set out for
yourself: it is your addiction, it is your recovery, and it is your responsibil-
ity, hard work, and sweat that will keep you sober. Ultimately, you are the
driver of this car. Drug counselors sit in the passenger seat next to you.
They point out helpful landmarks along the road, and they suggest driving
techniques that will keep you safely on the right course. In real terms,
counselors use their experience with addicts to help you understand your
addiction more fully, alert you when your addictive side starts to act up,
and lend you their experience in coping with the difficulties of recovery.
An effective counselor must have experience working with addicts,
recognizing addictive behaviors, and being familiar with skills to cope with
cravings. A counselor needs to be supportive and empathic but also needs
to when you veer toward drug thinking. Confrontation is usu-
confront you
ally uncomfortable, and if you become defensive, it can seem downright
offensive. A defensive reaction tells you, "This person doesn't know what
I'm going through and has no respect for me!" But counselors are actually
being empathic with the part of you that wants to stop crystal, the part
of you that is asking for help. They are showing you tremendous respect
by believing that the sober part of you is strong enough to succeed. The
counselor's job is to point to subtle signs that addictive behavior may be
sneaking back into control.
If your counselor says something that makes you angry, think again of
that AA expression "Take the cotton out of your ears and stick it in your
mouth. Stop the automatic impulse

"
to argue back, try to open your mind,

and ask yourself what is making you so upset. If you search really hard, you
may see that your addict side is yelling back because it feels threatened.
If this is so, your counselor may be doing excellent work — making your
addict side feel so threatened means that your hard work is paying off and
the addict side is losing control.
While having a drug counselor experienced with cr\^stal is ideal, many
areas still lack health care professionals who are very knowledgeable about
meth. Nonetheless, a general drug counselor can still be helpful. The
principles of recovery apply to all addictions, regardless of the specific
drug. Crystal-specific knowledge can provide additional benefit, but if it's
not available, dont turn away from the valuable resource that you do have.
Take the opportunity to learn the basics of addiction recovery.
Some of you may find that you know more about meth than your drug
counselor, and you may have to teach him or her a few things about the
drug. Avoid the assumption that this person is therefore unable to help
you.The fundamental problems of all addictions are the same, and you
need someone who understands addictive behaviors and has experience
in helping people overcome them.
If you are already seeing a psychotherapist who was not aware of your
crystal addiction, and now you need to work on sobriety, you should keep
the focus of your sessions on achieving sobriety and learning relapse pre-
vention skills before moving back to the other life issues you usually dis-
cuss in your therapy. While it may be tempting to talk about your troubled
childhood that led to your difficulty with relationships today, you need to
shelve that important topic for later. There are three reasons for this:
Most important, you need to devote all your mental energy to getting
off crystal and learning specific skills, which you need now to cope with-
out crystal. It takes tremendous work, so take it seriously, and devote the
time to it that it deserves. Your brain is in the physiological grip of a strong
chemical addiction that supersedes logical thinking. While understanding

the childhood experiences that may have led you to addiction are impor-
tant, that understanding is not helpful now. Stopping crystal and learning
how to keep off the drug are more pressing at this time.
In addition, exploring life issues in therapy can increase distress.

Exploratory therapy, as opposed to relapse-prevention therapy ' usually
causes emotional discomfort as you uncover buried issues —your mind
originally buried them because it was too uncomfortable for you to keep
them at a conscious level. In long-term therapy, uncovering issues is nec-
essary in order to examine and address them. However, this is a long-term
process. When you are first trying to achieve sobriety, adding additional
stress just when you are trying to stay away from drugs can make you fall
right back into them. At this time, you should focus on developing skills
to protect yourself from uncomfortable feelings and avoid exploring things

make you more upset and fall back on your most familiar coping
that will
mechanism, crystal. Once your skills at handling difficult feelings without
drugs are stronger, then it will be time to go back to exploratory therapy
In the long run, understanding these roots of your character my help your
addiction, in addition to the rest of you life.
Finally, issues other than sobriety may seem important in therapy, but
they may just be distractions created by the sneaky addicted part of your
brain, trying to divert your attention away from sobriety The insidious
addict in you may try to convince you, "If only I could resolve my troubles
in this one particular relationship, then I wouldn't need crystal anymore."
Meanwhile, focusing all of your sessions on the ups and downs of your
relationship rather than developing skills to stop meth leaves you vulnerable
to keep using. The addict in you quietly hopes that this tactic can buy you
months to years more of crystal use before you and your therapist realize
that therapy has just been going in circles, while your addiction to meth has
gotten worse. Wait until you have acquired the skills to face stress without
relapsing. Then you are ready to work on other life issues safely.
TWELVE-STEP PROGRAMS
Twelve-step programs are probably best known by their earliest incar-
nation. Alcoholics Anonymous (AA). This group was designed as a
''spiritual" way of dealing with addiction by Bill Wilson AA as
(known in
Bill W.), a Wall Street market analyst, and Dr. Robert Smith (known in AA
as Dr. Bob). Both Bill W. and Dr. Bob had been active alcoholics. Bill W.
had been through multiple treatments and attempts to stay sober, at times
being told that he was a hopeless case because of his repeated relapses.
In 1935, Bill W. and Dr. Bob met each other, and during their long dis-
cussions about their mutual addictions, they experienced something new.

Telling one's experience and sharing it openly with someone who validated
it from his own personal experience was something that neither of them
had ever encountered in the past, either in the medical system or religious
communities. That moment is considered the birth of the original AA.
Since its meager beginnings with a small group of alcoholics gathering in
Akron, Ohio, AA has now grown to more than 2 million members, with
more than 100,000 groups in over 150 countries.
Originally AA was heavily influenced by religion and incorporated a
Christian-centered devotion to God; however, the fundamental ideas have
been useful to people of all religious or nonreligious backgrounds, and
AA groups are successful in non-Christian countries, such as Cambodia,
Israel, and Dubai.
The following are important concepts that address the core issues of
addiction:
1. Admission that one has an addiction.

2. Admission that one is powerless against the addiction.
3. Submission to the powerlessness.
4. Reaching out for help from others.
Addicts usually do not recognize, or will not admit, that they have a prob-
lem, often until it is too late. Even when meth addicts suspect that their use
is growing beyond their control, they keep themselves in denial, and so are
reluctant to talk about crystal as if it were a problem. As they try to hold on
to the fantasy that they still have control, their addiction grows stronger. A
key concept of twelve-step programs, which is echoed several times in this
book, is the ability to "let go." Addicts teach themselves through repeated
drug use that they can "control" their world. When something does not feel
right, there is always a pill, a drink, or another drug that can make them feel
better. The fact that crystal users often know more about the drug than many
physicians reinforces their conviction that they know better than anyone
else what they need, and that they can control everything in their lives.
This is one of the biggest obstacles that addicts face, and it is the first of the
twelve steps: admitting one is powerless and letting go of the control.
"În the United States, depending on which meeting you attend, the language of the group
may still have a heavily Christian feel, but belief in a Christian God is not an essential part of
the current AA philosophy. one group seems too extreme in its religious orientation
If for your
comfort, tv)' another, and hopefully you will find one that is a better fit.
THINGS YOU CAN DO TO BEAT CRYSTAL ADDICTION I I4I
Another powerful aspect of twelve-step programs is the fellowship with

other people who have the same addiction, i.e., finding a group of people
who really understand you. Speaking with other crystal users in recovery
is powerful. You hear the words of other people who have experienced the
strong grip of this addiction —the amazing highs, the nightmare crashes,
the irresistible lure of the drug, and the gradual destruction it can cause
in your life as you watch things fall apart, unable to resist the draw to
use it again. People whoVe never tried meth can only try to imagine what
you've experienced, whereas these people knoiv because they have been
there. At twelve-step meetings you hear other people tell stories similar to
yours, and you have the opportunity to share your experiences and receive
support from understanding peers. Telling your stories, good or bad, can
inspire others to stay clean, and hearing the tragic stories of others may
give you more motivation to stay clean.
The benefit of peer-led groups goes beyond empathy and support.

Because people in the groups have been in your position, not only do
they share the addiction and the desire for sobriety, they also share the
experience of relapsing. They can see if your life is veering in a dangerous
direction —overloading yourself with stress or unrealistic expectations,
repeating behaviors that have gotten you into trouble with crystal before,
or rationalizing and allowing dangerous triggers of meth back into your
life. Peers can confront you and "call you on your B.S." with a convincing
authority that non-crystal users can never have. It is much easier to ignore
the advice of someone who does not know what it is like to be hooked
on crystal. However, when the same words come from another addict in
recovery, they may shake you up enough to actually stop and listen.
Every new member of a twelve-step program finds a "sponsor," a senior
member with a substantial length of sobriety to whom the new member
can look for support and mentorship. The sponsor is supposed to be avail-
able whenever the new member is feeling weak, trying to fight off cravings.
Rather than reach for a drug, the member can reach for the phone, and
often, speaking with the sponsor helps to abort a potential relapse.
Twelve-step groups now exist for all types of addiction, even non-drug
addictions, such as addictions to food and sex. When Crystal Meth
Anonymous (CMA) was first formed, there were few meetings, and those
were poorly attended. Now in most major cities, CMA meetings are plenti-
ful and often packed to standing-room capacity. Clearly there is a need for
even more CMA meetings, as existing meetings are over capacity; in many
towns, CMA meetings don't yet exist. For specific information about the
closest CMA meetings to you, visit the Web site www.crystalmeth.org,
which frequently updates lists of meeting locations and times throughout
the country. Fortunately, the list of CMA meetings continues to grow to
try to meet the expanding need.
Many people underestimate the power of peer-led support groups such
as CMA and AA. Initially the medical community was extremely skeptical
about twelve-step groups, with many physicians feeling that addicts getting
advice from other addicts was like the blind leading the blind. However,
studies have shown the tremendous impact of twelve-step meetings. A
study by McKellar and colleagues in 2003, and another by Moos and Moos
in 2004, demonstrated that people who were more involved in AA were
more likely to be sober than those less involved, and this effect persisted
up to eight years from the time of joining AA. Another study by McKellar,
Stewart, and Humphries in 2003 looked at the effect of attending AA in a
group of 2,319 men in the Veterans Affairs hospital system. Interestingly,
motivation to be sober and belief in the AA program itself had no correla-

tion with success. Even those reporting low motivation stayed in recovery
longer if they continued to attend AA meetings.

Even if you are doing other things to try to address your crystal addic-
tion, attending a twelve-step program can still be extremely helpful. A
study by Timko and colleagues in 2000 showed that people who added
twelve-step groups to "traditional" addiction treatment more than doubled
their rate of staying clean, and they had maintained this benefit when they
were followed up three years later.
The message is that peer-led twelve-step meetings are helpful, and sta-
tistically speaking, even if you don't like them, they significantly increase
your chances of staying clean. Without an answer to how or why they work,
for whatever reason, they are associated with a better outcome, which is
what matters most.
CRYSTAL METH ANONYMOUS (CMA)— THE GOOD AND THE BAD

Peer- LED support groups should be part of any recovery program, in
addition to your own personal efforts, individual counseling, medications,
THINGS YOJ CAN DO TO BEAT CRYSTAL ADDICTION I 143
or whatever else you Ini helpful. In addition to the concepts discussed

above, the anonymity ot these organizations is crucial. Some meetings are
"open" to anyone who would like to come. Others are "closed" meetings,
only for people who are established CMA members. There is an implicit
understanding that CMA, and all other twelve-step groups, are completely
confidential. What happens in "the walls," referring to the meetings, stays
within the walls, and identities are never revealed outside. The safety of
the anonymity is crucial to allow you to feel as trc^ as possible to open up

and be as honest as you can to yourself, as well as to otiiers.
Because ClMA meetings are relatively new and pockets of the crystal-
using community in major cities are relatively concentrated, CMA meet-
ings do not always feel anonymous. Even in large cities, such as New York
and Los Angeles, you may recognize many faces people in your social —
circle or people you may have even hooked up with on the Internet or at
sex parties. On the one hand, this can be a good thing. Seeing familiar
faces strongly reinforces the message that you are not alone. You can
already see this by the crowd of people at many of the meetings. However,
seeing people that you already know in your life drives the point home.
Maybe you thought that among your group of ciystal buddies, you were
the only one with a problem. However, by seeing them at CMA, you know
that you are not the only one struggling with meth addiction.
On the other hand, when people are still too afraid to let their friends or
family know about their cn^stal use, seeing familiar faces can create more
fear than reassurance. In that case, the chance of seeing people you know
may deter you from ever visiting a CMA meeting. In that case, tiy an AA
group or a Narcotics Anonymous (NA) group first. All twelve-step groups
use the same principles, though the flavor and the stories may var}^ a little. At
the beginning, the most important task is to join a group of peers with whom
you feel comfortable who share the determination to be sober. Even with
AA and NA meetings, it usually requires attending several different groups
to find one that feels comfortable for you. After developing more strength
in your conviction to stay clean and less shame about your addiction, it may
matter less that you recognize people at CMA, and if it is helpful, you can
tiy to attend a CMA meeting again. Because it is specific to your drug of
choice, you will hear stories and can share experiences that you may relate to
more strongly. For example, cr)^stal can give people uncontrollable, intense
144 I
OVERCOMING CRYSTAL MET'
are difficult
sexual experiences that ^^^^ understand. Sharing
advice about deaiiu^^
one's difficulties and getting ^^^.^^
whatever feels b^^
CMA meetings. But decide
comfortahj^^
Even if you decide you are ^.^^ recognize that not
appropriate
every CMAmeeting is
^^^^ individual. Again, find the
that feels like the best fi^ example, if you are newly
meeting
fc^.
sober and you are looking ^.^jg j-ôdels and success stories to inspire
you, then groups with ^;/;[y ^^^^ members may overload you with too many
stories of \icious struggles with sobriety and frequent relapses. Also, seeing
recent crystal-sex partners in meetings may be a strong a trigger rather
than a source of support. Some meetings may feel like people are coming
just to pick up someone for crystal sex. The unfortunate reality is that it
happens. If you find this, go to another meeting. If the members of one

meeting are so different from you that you find it difficult to relate, try
another group. Now there are enough meetings that groups have taken on
different flavors, and you have more of a choice. If that's not yet the case
where you live, try AA meetings, which, because of their long history, have
a much wider variety from which to choose.
One of my patients working on alcohol addiction was an upper-middle-
class former beauty pageant winner in her midforties. Initially she insisted
on attending meetings with people whom she described as "totally down-
and-out." Many of the members were homeless, and some were schizo-
phrenic. She rationalized that seeing how badly addiction could affect
people would motivate her to stay sober. However, in reality she used the
dramatic difference between her and the group members to convince
herself that she was not nearly as addicted as the others in the group, so
was not open to their support, and she convinced herself that she did not
really have any problem with addiction. She relapsed very quickly. After
detoxing, she found it was much more difficult for her to attend groups
with people who were similar to her because she had to confront her
own addiction more directly — at those meetings, she could see different
aspects of herself in the other people in the room. This was frightening
at the beginning, but eventually she was better able to admit her own
addiction, and eventually she was able to accept both her own illness and
the support and advice of people in the group because they were more
similar to her.
Unfortunately, some places have ver\' few CMA, AA, NA, or other
twelve-step meetings. In this case, you may not have the luxury of choos-
ing from a long list of meetings to attend. Finding the best fit is optimal,
just like choosing the right-size coat. However, even the wrong-size coat
may give you some protection from the cold. In the same way, you may
still benefit from a twelve-step program with people who are not exactly
like you. At least give the twelve-step meetings a try, and attend at least
five different meetings before you give up and say there's no possibility
of getting any help from these groups. The other pieces in your recovery
program, such as a drug counselor, can help you look for useful elements
in the groups. However, do not let yourself fall into the trap of rational-
izing, like the patient I described. Describe the group and discuss your
reactions with an addiction professional to discern whether the group has
any beneficial or potentially harmful effects on you. If you are clear on its
limitations, you may still be able to benefit from a group that isn't exactly
a perfect fit.
INTENSIVE OUTPATIENT PROGRAMS

If you are having trouble staying clean despite working regularly with
an individual counselor and going to twelve-step meetings, you may
need a higher level of treatment. Intensive outpatient programs (lOPs)
that address addictions are the next step up. Usually lOPs consist of a
more intensive and structured schedule of individual counseling, support
groups, education about drugs and addiction, and twelve-step meetings.
The frequency and intensity of the activities vary, and programs are usu-
ally tailored to each person's needs. Some people require daily treatment
to keep themselves away from crystal and some just go a few days a week.
Some people's daily treatment eventually trim down their participation to
only two or three evenings each week, which keeps them in a structured
program while they integrate back into their day jobs.
CRYSTAL-SPECIFIC TREATMENT PROGRAMS
While the majority of lOPs are general and include people with addic-
tions to all kinds of drugs, a program designed specifically for the needs
of crystal users would be even more helpful to you. This makes intuitive
sense, because crystal-specific programs focus more attention on the prob-
lems that are most common for meth users.
Let's take gay male crystal users as an example. Some closeted gay men
were first introduced to the gay community in the setting of nightclubs and
circuit parties, where many of these men were first able to feel comfortable
and excited about their sexuality, rather than ashamed. In these settings,
club drugs such as Ecstasy, ketamine, GHB, cocaine, and crystal were
commonly used, and drug use in these places was the norm. For these
men, crystal, as well as the use of other club drugs, was attached to the
joyously liberating experience of coming out and finally feeling free about
their sexuality. For these men, the emotional meaning of crystal is much
more complicated than just feeling high or enjoying sex. Rather, crystal is
also associated with life-changing memories of finally accepting oneself

and one's own sexuality, and by using drugs, these men were able to bond
w ith a like-minded community. Mourning the loss of the intense high that
crystal gives is difficult by itself. But these men are also being forced to
reject a social scene with strong emotional meaning. And for those whose
social network is still primarily drug-using club-goers, the ver)^ people who
made them feel accepted —how will they turn their backs on them? And
without them, will they be as isolated and alone as they had been before
coming out? Again, Nancy Reagan's Just Say No campaign oversimplifies
the complexity of addiction. The act of quitting a drug needs to be fully
explored to help people quit. In this case, these gay men needed to find
healthier ways to accept their sexuality, find healthier peers, and improve
their self-esteem.
The example of gay male crystal users is only one of many. Every type
of crystal user —from teenage girls with eating disorders to young men in
the rural South, struggling with boredom and low self- worth —has a story
that needs to be explored, and their underlying vulnerabilities need to be

addressed specifically, as well, to reduce the chances of their turning back
to cr)'Stal.
Finding Mutual Support Brian's story
When Brian, a lawyerp was discharged from the hospital, he went

directly to a residential drug-addiction treatnnent facility that specializes
in crystal addiction. He explored his gay identity and the significance of his
connection to the gay connmunity through clubs and drugs. He wrestled

with a tremendous fear of giving up this part of his life and feelings of
J
guilt for turning his back on the social group that finally allowed him to 5
accept himself as a gay man. His fellow circuit partyers were his family.
i The entire social scene surrounding his use of crystal was extremely
important to him. Trying to convince him to "avoid people, places, and
things" to completely kick the drug and everything that came with it was
much harder than he had imagined.
Sex was another intensive focus in Brian's groups. In other programs,
he felt that non-meth users had no idea what crystal-sex was like, and
they didn't comprehend the intensity of the compulsive need to feed his
turbocharged libido, or the disappointing emptiness of sex without crys-
tal. In this group, the members started from a point of common under-
standing. There was mutual support, but in addition, the group worked
on specific strategies for dealing with sex: understanding the different
I components of sex. realistic expectations about sex in the future, mourn- I
ing the loss of crystal-sex, and exercises to relearn aspects of sex that
were lost when he was using crystal. Mourning crystal sex continues to
be a struggle, but Brian felt more hopeful, glad that he was actively work-
ing on something important to him rather than simply being told, "That's
terrible, but everything will get better with time."
i After Brian finished his inpatient rehabilitation, he continued to go
to CMA meetings, where he was surprised to find other people he had
seen at circuit parties and sex clubs. Some had been sober for over a
year, and some who recently joined were going through a lot of the same
early struggles that Brian had experienced. In groups with gay men who
were just recently clean, he was able to give and receive mutual support, f
However, at times Brian found those groups difficult because they stirred
up old memories and triggers. Many of the newly sober men kept relaps- |
ing, and some openly invited Brian to have sex with crystal. Fortunately
r
j he was smart enough to change to an early-nnorning group, with other
i professional men who were more like Brian. They were motivated to stop
because they had long, successful careers that were in jeopardy. Brian's
law firm was still unaware of his drug-use problem— he was extremely
^ discreet and paid for all his treatment with his own savings. He never filed
health insurance claims, and he used vacation and sick leave to take time
I
off from work for his rehab. Brian watched some of his crystal buddies
; who had also been successful professionals in their late thirties lose their
jobs, lose their professional licenses, and move back in with their parents
as if they were teenagers. He knew his job was on the line, and after work-
ing so long to be an attorney, he was determined not to let crystal take
away everything he had worked for. i
Men and women who used crystal primarily during sex often fear that
sex will never be enjoyable without crystal. Sex itself becomes a tremen-
dous trigger to use again. For human beings, sex is a natural desire that
will always be there. How do these people cope? Do they ever have that
level of pleasurable sex again? These questions need to be discussed be-
cause the issue of sex will never go away and cannot be ignored — it is one
of the toughest aspects of crystal addiction. What are some coping skills
to handle sex during the early stages of recovery? How can one relearn
how to have sober sex and enjoy it? A comprehensive treatment program
identifies these areas and teaches skills to cope with problems as well as
exercises that may improve these areas. In this example, sex is the issue,
but for others, the issue may be body image, self-esteem, stress manage-
ment, and self-expectations. Specific topics, when effectively addressed in
a supportive environment, have been shown to improve abstinence rates
for crystal addicts.
THE MATRIX MODEL

A CRYSTAL-SPECIFIC program addresses the examples above as well as
others in focused support and educational groups. One of the earliest

models of crystal-focused treatment is the Matrix Model, developed by a
group of addiction specialists at UCLA. The Matrix Model is an intensive

treatment program based on traditional relapse-prevention concepts, with

a specific focus on methamphetamine.
Large-scale studies comparing crystal addicts in Matrix Model programs
with crystal addicts in treatment-as-usual (TAU) programs found that
crystal-specific treatment kept people engaged in treatment longer,
reduced the number of relapses (verified by regular urine drug tests), and
helped addicts to sustain longer periods of complete sobriety. Although
both types of programs showed improvement, those in the crystal-focused
program improved significantly more.

A follow-up study of subjects one year after completing intensive treat-
ment found that the advantages of the crystal-focused programs gradually

disappeared, and all the patients, regardless of the type of lOP treatment
they received, looked identical as far as relapsing. Any advantage that the
Matrix Model had initially provided was lost. While crystal-specific lOPs
have a clear advantage over TAU, more crystal-specific services at all levels
of care are necessary to provide lasting benefits following lOP programs.
INPATIENT OR RESIDENTIAL REHABILITATION
Many people are familiar with the concept of twenty-eight-day treat-

ment programs, made well known to the general public by the movie 28
Days, starring Sandra Bullock. This inpatient form of addiction treat-
ment is used when people have already tried to stop using crystal several
times but, no matter how hard they try, they continue to relapse, and they
begin to face increasingly dangerous consequences —problems with their
health, their job, their relationships, or other important aspects of their

lives. Depending on where the program is located, it can be an inpatient
program, meaning that it is physically located within a hospital, or it can
be a residential program, which is a freestanding facihty without other
hospital services. Residential programs are often located in secluded envi-

ronments, where addicts can peacefully focus on recovery..
Inpatient and residential treatments, as with all other addiction treat-
ments, work best when addicts can admit to their illness and are motivated
to stop using crystal. However, even when people lack complete insight
into their illness, these treatments can still be helpful. This situation
of ambivalence and limited insight most often occurs when a person is
pressured into treatment by family and friends during an intervention, or
/
if a criminal court mandates that someone receive intensive inpatient or

residential drug treatment.
Inpatient treatments remove addicts from their usual environments.

Removing as many triggers as possible —the people, places or things that
they associate with crystal use —reduces the intensity of their cravings,
and they are better able to focus on treatment.
In a controlled setting, access to meth is extremely difficult, so despite
any urges to use, addicts are physically unable to relapse as long as they
remain in the program. Sometimes breaking the cycle of use, getting com-
pletely through the crash, and simply reexperiencing sober thinking again
helps tremendously to clear their perspective about the effects of addic-
tion on their lives. During both the high and the crash, addicts' thinking
is impaired, and their judgment is affected by extremely strong cravings.
Forcing themselves to clean up in a protected, drug-free environment gives
addicts a much better start on recovery.
The intensity of inpatient treatment gently but firmly confronts meth
addicts and forces them to look at how the drug controls them and how it
has affected their lives. Optimally, this is done in a supportive way, because
harsh confrontation is usually met with strong resistance and denial —the
addict just becomes more adamant that he or she has no problem with
drugs. However, through a more gradual process of working through edu-
cation, self-examination, and learning from other addicts, many skepti-
cal people leave inpatient rehabilitation with improved insight into their
addiction, and, it is hoped they have internalized some of the skills to help
them stay in recovery.
The actual length of stay at these programs is not necessarily twenty-
eight days. Each program sets its own standard, and within each program,
the length of stay usually is determined by the severity of each person s
addiction. Often, insurance plans will partially cover the expense of a reha-
bilitation stay. Rehab facilities can vary from low-cost city hospitals to ex-
pensive spa-like retreats in secluded or exotic locations. Cosmetics aside,

all good programs should have the same basic treatment strategies:
Individual counseling to closely address personal needs

Support groups
Educational groups that teach about crystal and addiction
Twelve-step meetings
Teaching skills to manage stress without drugs

Teaching skills to cope with cravings
Teaching drug-refusal skills
Exploration of the family of origin, examination of family dynam-

ics, and active participation of the family and other close sup-
porters in the treatment
Establishing a plan for how to manage life after leaving program,
including connecting you with a drug counselor or therapist,
psychiatrist, outpatient program, or whatever is determined to be

necessary to maintain the benefit from residential treatment
If you look make sure that all of these

for inpatient or residential care,
treatments issues are addressed. In addition, make sure that any program
you are considering is certified by the Substance Abuse and Men-
tal Health Services Administration (SAMHSA), a U.S. government
agency that ensures that programs meet or exceed the standards of care set
by its state government. This means that the program has been approved
by the local state alcohol and drug abuse authority as a substance abuse
treatment facility and has responded to the most recent annual National
Survey of Substance Abuse Treatment Services. Be wary of programs that
are not accredited. While they are usually cheaper, this is because they cut
corners in necessary treatment modalities and medical supervision. Spend-
ing money on a program that does not offer effective clinical treatment
is a tremendous waste and risks turning you off to trying other treatment
programs that may benefit you greatly. Visit the SAMHSA Web site at
http://dasis3.samhsa.gov. You can also contact SAMHSAs Office of Com-

munications by telephone at 240-276-2130, or e-mail [email protected].
Another important accrediting organization is the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO), a private, not-for-
profit organization that assesses thousands of healthcare facilities. If you

are considering a program that administers medical treatment, then make
sure that it has been certified by JCAHO, which requires strict standards
that every medical facility should meet. The emphasis of JCAHO has been
on ensuring patients' rights and safety, though to some extent, it also evalu-
ates how well a program meets its clinical goals. Because JCAHO does
not specialize in addiction, accreditation from SAMHSA will ensure your
medical safety and the quality of your addiction treatment. You can contact
JCAHO by mailing their headquarters at One Renaissance Boulevard,

Oakbrook Terrace, IL 60181, or by calling their main telephone number,
(630) 792-5000. Visit their Web site at www.jointcommission.org for fur-
ther information and to check if a program you are considering has been
accredited by JCAHO.
Over the past few years, several addiction programs have sprouted up,
specifically addressing the treatment of addiction to crystal meth. This is
fortunate, because, as research shows, crystal-specific treatment has been

shown to have better results. However, some of these new programs and
facilities are simply opportunistic, exploiting the devastating health prob-
lem of meth addiction. They may offer treatment that is not based on any
proven methods or have counselors and clinician's who are not qualified to
help you. Therefore, be wary of large for-profit organizations reaching out
to you with magazine ads and billboards —they may be more interested in
your dollars than in providing you the best help possible. If such a program
looks appeahng, check with SAMHSA and JCAHO or your state's drug and
alcohol treatment services administration to make sure that an advertised
program is legitimate.
How do you know if an inpatient rehabilitation program is right for you?

Here are some practical guidelines:
1. Have you been completely unable to stop using crystal, despite
several attempts at throwing it all away and trying to stay away

from triggers?
2. Have you already tried going to CMA meetings and seeing a drug
counselor or a therapist experienced with addiction, but you still
keep relapsing?
3 . Are you having significant medical or psychiatric problems because
of crystal use, e.g., possible heart or lung problems, dental problems
C meth-mouth "), episodes of paranoia or hallucinations, severe de-

pression, or suicidal thoughts, but you continue to use?
4. Have you tried intensive outpatient drug programs but they have
not been enough to get you to stop using?
If you answered yes to one or more of these questions, then you should
consider inpatient treatment. If you answered yes to question 4, then you
definitely need more intensive treatment in an inpatient or residential

setting.
Many private and group health insurance programs cover some addic-
tion treatment, Usually the most important requirement for insurance
coverage is documented failure in outpatient treatment. Ask your insur-
ance company whether it covers inpatient treatment and what the criteria
are, because the definition of failing outpatient treatment is arbitrary — it
could mean relapsing after seeing a therapist weekly and going to CMA,
or it may require a trial of an lOP before inpatient care is even considered.
Significant medical or psychiatric illness resulting from drug use will also
strongly support your case for coverage.
Unfortunately, most insurance companies are difficult to navigate,
and when you are struggling with an illness, it is even harder to negotiate
the system. If you are working with a therapist or counselor, ask for help
getting through the insurance maze. You can also ask for assistance from
your doctor's office manager, a family member, a friend, or a coworker.
Self-Esteem Takes Many Years to Build ana's STORY
At firstp Ana had a very difficult time with treatment. She was sent
to a drug-treatment facility for teens, where she met other teenagers

who didn't want treatment but who were also forced by the court or by
their parents to be there. She had little insight into her own addiction,
and she saw no problem with meth, viewing it as a successful way to be
thinner and prettier. Even worse, she blamed her withdrawal symptoms
of depression, irritability, and hunger on the program staff, using this
as evidence that she was correct in her use of the meds. The doctors'
advice to stop meth had only made her feel worse. Ana began hang-
ing out with the teens who were the rebels of the program. Some of
them were disruptive in group, speaking up only to ridicule the group
or challenge the group leader. Ana was one of a handful of girls who
just sat silently, staring angrily at the floor and refusing to contribute to
the discussion. After a week, when the irritable depression of her crash
began to wane. Ana began to listen to some of the teens who spoke
i
constructively in the group. Although she had originally been angry
and had resented the teens who "shared," she started to hear some of
what they were saying. Once in a while she heard things she strongly
identified with, things she had thought nobody else understood.
Ana made friends with Karen, a sixteen-year-old middle-class
Caucasian from San Diego, who had also been trying to lose weight and
never felt that she was pretty enough. She understood exactly what Karen
meant when she shared in group her frustration with her parents and
other adults who she felt had never taken her seriously when she'd com-
plained about how competitive and vicious her high-school classmates
could be. Crystal not only made her thinner than her classmates [and
prettier, she believed), it also made her feel more confident, immune to
the catty stares from the "princesses" m her class. She loved the way the
drug made her feel so much better about herself, but she dreaded when
its effects would wear off. At times, she saw how trapped she was in using
crystal to survive high school, but it was a jungle, and she needed a way
to survive. Karen spent most of her time focused on getting more meth.
Even when she was feeling anxious and irritable from getting high, she
still wanted to keep doing it.
Karen told the group that on meth, she had been gradually deteriorat-
ing: one day she passed out in a shopping mall from dehydration and
malnutrition. An ambulance brought her to the hospital, and a social
worker transferred her directly to this addiction treatment unit. She would
never have come on her own. But now that she had been in the program
for three weeks, she was beginning to look back on her life with crystal
through clearer eyes. Although she had put on weight, her face was still
gaunt, and without the rosy glasses of meth she saw m the mirror how
sickly she had become. Finally she saw in her own reflection the ugly side
of what crystal had done to her.
Karen's story was so familiar to Ana, even though she was one of
this girls whom Ana would have resented at her own school in L.A. She
was surprised how similar she felt. Here, someone that she would have
envied for seeming "perfect" was talking about her own weaknesses and
fears, which were identical to Ana's. The sense of connection seemed to
give Ana permission and courage to open up about her own feelings, and
she began to share her own experiences in groups. She distanced herself
from the rebellious teens and began to focus more on trying to feel bet-
ter about herself. Without crystal to magically transform her, she had to
work hard at changing her feelings, Even though this was a slower, harder
process. Ana realized that crystal was only a mask she hid behind to look <
pretty, but she was the only one fooled by the mask. j
'
Ana worked hard in her rehab program, making gradual progress.
Self-esteem, people told her, was something that would take years for
her to build, and for many it would be a lifelong process. There were plenty
of times when Ana longed for crystal because she remembered the quick
relief it gave her She craved meth the most when she was feeling tired,
frustrated, or unattractive. Luckily she was in a protected environment,
and she learned to talk to Karen when she really wanted to use. That
helped some.
After six weeks. Ana finished the program and returned to her family
in L.A. in the middle of that summer She went to teen AA meetings and
stayed sober, keeping in contact with Karen as her "sober sister" However,
in the fall, when she returned to school, she started to buckle under the
pressure of the competitive girls in her class. Once again she felt unat-
tractive and worthless. Quickly, she fell back into her old pattern of using
crystal to cope. She stopped calling Karen because she was embarrassed
to tell her that she had relapsed. Part of her also didn't want to hear what
Karen would tell her— that she should stop the crystal.
Ana ended up in rehab a second time, and afterward she was referred
to an intensive outpatient program to help her make the transition back
as she faced the pressures of high school. She is continuing to attend
groups and AA meetings. Although she is trying to build a network of
friends who are sober and supportive, she finds it extremely difficult in
a community of high-school students who like to party with alcohol and
drugs. She has already slipped a few times, using crystal on a few occa-
sions, but fortunately she keeps going to meetings and groups, and none
of the slips have turned into a full-blown relapse yet. After a slip, she is
sometimes able to call Karen, and she thinks this may have saved her
from another full-blown relapse. Every day Ana reminds herself what she
learned during her first rehab: self-esteem is something that can take
years to build, and for many it's a lifelong process.
ACUPUNCTURE
In recent years, increasing numbers of people are turning to alternative
medicine to treat physical and emotional problems. Because of my work
in addiction, I try to teach people to learn new ways to manage emotional
discomfort without automatically resorting to pills, though sometimes
medication is truly necessary. The addiction-treatment community has
long turned to acupuncture as a nonmedication alternative for some of the
problems associated with addiction and withdrawal.
One of the earliest pioneers in introducing acupuncture to the addiction-
treatment community was Dr. Michael Smith at Lincoln Hospital in the
South Bronx of New York City. He opened a drop-in center where people
wishing to stop heroin could come for acupuncture to ease their withdrawal
symptoms without resorting to medications. Dr. Smith has been criticized
by many who say that acupuncture is a scam. However, Dr. Smith also has
a large group of supporters: people coming off the streets, almost all of
them heavy heroin addicts, many of them homeless. They come in feeling
dope-sick and distressed, they line up for acupuncture, and after receiving
treatment, they appear remarkably calm and comforted. While the use of
acupuncture for medical uses is hotly debated, there is no question that
many people receiving treatment at Lincoln Hospital in the South Bronx
feel relief.
Most heroin treatment centers that use acupuncture only target needle
points in the ear. These points seem to offer heroin addicts the most relief,
and because the area is so limited, certification is easy and staff can easily be
trained, making the service available to a large number of people. If you are
able to see a practitioner who is fully licensed in acupuncture, you can get the
additional benefit of treatment with points other than just the ears, balancing
the entire system and providing even greater relaxation and relief.
We will discuss acupuncture in more detail in chapter 17, which

includes the general principles of how acupuncture works and how you
can find a licensed acupuncturist near you.
MEDICATIONS
Medication for crystal addiction remains a new and evolving field

as medical science learns more about the biology of the brain and the
neurophysiology of addiction. I have already discussed the use of medica-
tions for detoxification from acute withdrawal. Here I will discuss several
medications under investigation for maintenance treatment of metham-

phetamine addiction, with the goal of decreasing craving and reducing the
number of relapses.
In the past, most of the attention to stimulant addiction, including
methamphetamine and cocaine, focused on dopamine agents because

stimulants affect dopamine, and this is the major chemical that mediates
the brain-reward circuit of addiction. While this pathway is a fundamen-
tal part of addiction, there are also many other brain processes, neural
pathways, neurotransmitters, and intracellular "secondary messengers"
involved. In lay terms, it means that addiction is much more complex than
just the dopamine-reward pathway. Unfortunately, nothing as simple as
controlling dopamine has turned out to be a magic bullet. To add to the
confusion, drugs that increase dopamine stimulation and drugs that block
dopamine stimulation both seem to have beneficial effects on reducing
stimulant use in animal studies. Most recently, studies have found that the
best effect comes from dopamine partial agonists, which share properties
of both the dopamine stimulators and the dopamine blockers.
Other brain structures, such as the striatum, the cingulum, and the
cerebral cortex, have been found to have their own important roles in
addiction, Neurotransmitters in these areas, such as glutamate, glycine,

and gamma-aminobutyric acid (GABA) are currently under investiga-
tion. Dopamine receptors no longer monopolize the spotlight. Researchers ;
are also looking at mu-opioid receptors, GABA receptors, N-methyl-D-

aspartic acid (NMDA) receptors, cannabinoid (marijuana) receptors,
calcium ion channels, DNA gene transcription . . . and the list goes on
and on. The more that we discover about the brain, the more enigmatic
it becomes. i;
Because of this early stage in drug trials, it is not possible to make exten- \
sive comments on what medications may be helpful in preventing crystal

relapses. At this time, there are no medications approved by the
U.S. Food and Drug Administration specifically for the treatment

of methamphetamine. Therefore, I can only report on the limited
studies of different medications and comment on their theoretical
applications for the treatment of crystal addiction. I do not rec-
ommend using these medications to treat methamphetamine until
studies provide further evidence for their efficacy and safety.
Topiramate (brand name Topamax) is an antiseizure medication that
has been prescribed for pain from nerve damage, migraine headaches, and
anxiety. It was later found to reduce alcohol cravings and relapses. Further
research showed that it had a similar effect in reducing cocaine relapses.
The positive effect on cocaine addiction makes it a good candidate for
crystal addiction, because of the similarities between the two drugs. While
Topiramate is not addictive, it must be used carefully. It is started at a low
dose and gradually increased, because sudden increases in dosage can
cause severe mental confusion. Other side effects are decreased appetite
and weight loss, countering the hunger and weight gain that often occur
when you suddenly stop using crystal. If you are taking topiramate and
decide you want to stop, make sure to taper off gradually Because it is
an antiseizure medication, stopping topiramate abruptly can theoretically

cause a seizure.
Gabapentin (brand name Neurontin) is also an antiseizure medica-
tion. It seems to work very specifically on certain calcium channels in the
brain, though its exact mechanism of action remains unknown. Although

it functions differently than topiramate, it has been found to have many of
the same therapeutic effects, including decreasing anxiety and reducing
relapses on cocaine. Trials investigating its effects on methamphetamine
addiction are under way.
Acamprosate (brand name Campral) has long been used in Europe to
treat alcoholism. It is thought to work by increasing GABA function (help-

ing relaxation) and decreasing glutamate overactivity (decreasing anxiety
and brain toxicity), which occurs when alcoholics start to feel strong crav-
ings for alcohol. For people who have stopped drinking, it was believed to
prevent relapses by decreasing the intensity of the craving through its effect
on blocking overactive glutamate activity. Unfortunately, a recent large-scale

study showed that acamprosate was no better than a placebo at decreas-
ing alcohol relapses —while study subjects taking acamprosate showed
improvement, it was no better than the subjects taking sugar pills.
Naltrexone (brand name Revia) is an opiate antagonist, blocking the

effects of opiates, such as heroin. An intravenous analog called naloxone is
used in emergency rooms as an antidote for people who overdose on opiates
and stop breathing. Naltrexone, which is taken as a pill, has been used with
success in some alcoholics, possibly blocking opiate receptors at reward
and pleasure centers that are stimulated by alcohol. With less of a reward,
people may not feel as strong a desire to drink. There are other theories
about how naltrexone works, such as balancing out the opiate receptors
in the brain at its resting state so that the user is happier in general, thus
requiring less self-medication to elevate a low mood. Using this theory, nal-
trexone is now being investigated as a medication for crystal addiction. As a
pill, it needs to be taken every day. However, a long-acting injectable form

called Vivitrol was recently approved and is soon to be released. Requiring
only one injection per month, it offers protection to those in recovery who
are very motivated but have sudden moments of weakness, when they stop
taking naltrexone pills so that they can drink or use opiates. The most com-
mon side effects are stomach upset and rare irritation to the liver. People
with hepatitis B or C should be cautious with naltrexone.

Dopamine antagonists are medications that directly block the site of
action of crystal: the dopamine receptor. In animal studies, these drugs
demonstrate an excellent ability to block the effects of stimulants. However,

dopamine receptors are located throughout the entire brain, and in the long
term, this class of medication is associated with numerous neurological side
effects. It is not likely to be a good candidate for long-term use.

Medications that affect the GABA receptor are generally calming,
inhibiting brain cell transmission, including signals that instruct the brain
to use more drugs. Theoretically, medications affecting GABA should
lower the intensity of drug cravings and decrease the number of relapses.
Therefore, there is intensive research on these medications as treatments
for stimulant addiction. Clinicians are concerned about the addictive risk
of benzodiazepines. However, mild to moderate nonaddictive medications

that increase the effect of GABA, such as tiagibine (Gabitril) and baclofen
(Kemstro), have shown only modest benefit. Gamma-vinyl GABA (GVG)
is the strongest GABA medication available, and a recent study by Dr.
Jonathan Brodie found that sixteen of the eighteen people who remained
in his study had dramatic improvement in staying off meth. However, GVG
has a dangerous risk of patchy blindness, so studies on GVG were halted in
this country. Notably, none of the subjects in Brodie s study suffered vision
problems, though 15 out of 33 subjects dropped out of the study.
The last medication I will discuss in this chapter is modafinil (Provigil).
This drug increases alertness and reduces mental and physical fatigue. To
date, studies show that modafinil has an extremely low potential for addic-
tion and that it is effective at reducing and preventing relapses in cocaine

addiction. Imaging studies do not show any significant change in the
nucleus accumbens, which is usually activated by addictive drugs. For this

reason, it is being investigated as a treatment for methamphetamine addic-
tion, and at this time it looks to be one of the most promising treatments
currently available. Subjectively, meth addicts in acute withdrawal quickly
feel an improvement in their fatigue and the clarity of their thinking.
Modafinil's effect on methamphetamine addiction may be due to its
increase in glutamate activity, an important chemical in the brain that deals

with learning new behaviors, taking information and weighing options, and
then making logical decisions. In addiction, these brain activities affect
the ability to resist temptations to relapse. While dopamine and the meso-
limbic pathway are responsible for establishing the initial addiction, the
maintenance phase of addiction is believed to be mediated by glutamate.
Glutamate is used to communicate between the brain-reward pathway and
the prefrontal cortex, where logical thinking and judgments are carried out.
The function of this bridge is important because it determines how well a
person can make rational judgments in reaction to strong signals from the
brain-reward pathway telling it to use drugs.
In crystal addicts, the baseline level of glutamate activity is low, mean-
ing that the ability of the brain to make proper judgments is impaired, for
example, deciding whether to go to a party where all your old meth buddies
will likely be getting high. Modafinil seems to increase glutamate in areas
where it is too low, and perhaps it improves the ability of addicts to assess
their circumstances and make logical judgments.
Crystal users also have an abnormally high spike in glutamate when they
see a cue reminding them of crystal. They may experience the spike as a
rush of excitement when they hear their dealer's voice or see a picture of
a glass pipe that reminds them of times they've smoked. It is possible that
modafinil also lowers this spike, which may help addicts to resist sudden
urges brought on by the usual triggers that lead to relapse.
These are all theoretical conjectures about modafinil. The exact mecha-
nism in which it works is still unknown. Nevertheless, the early results of
current studies of modafinil as a treatment for crystal addicts have been

showing promising results. In addition, many physicians, myself included
prescribe Provigil in their practices and have seen their meth-addicted
patients improve. However, there are a handful of reports of people feel-
ing mild euphoria from modafinil. Two of my patients, both of them with
bipolar disorder experienced this. One of them was in recovery from crystal
meth. He reported feeling high and energized, with a strong compulsion

to take increasing amounts. The second patient was not an addict and did
not develop an addiction to the medicine, although he became extremely
manic, with racing thoughts, euphoric or easily irritable mood, and so
much energy that he needed very little sleep. Because both patients had
bipolar disorder, it is still unclear if the patient in recovery from meth
addiction was feeling hypomanic and impulsive from taking increasing
amounts of modafinil, or if he was having a pure drug relapse. The cau-
tionary point is that, while this medication looks extremely promising as a
treatment for crystal addiction, it must be used with caution.
Additional considerations about modafinil are that it is extremely expen-
sive and it interacts with a number of prescription medications, more rea-
sons to be cautious. For example, it increases the metabolism of protease

inhibitors (PI) for HIV and particularly affects ritonovir (Norvir). If the
PI level becomes too low, it is not able to kill HIV, and strains of the virus
that are resistant to the medication can develop and severely worsen the
person's health. Dr. Judith Rabkin at Columbia University studied the use of
modafinil for fatigue in patients with HIV. In that study, doses were kept to
a maximum of 200 mg per day, and there was no effect on the HIV medica-
tions in any of the study participants. I recommend caution if you take a PI:
be cautious with modafinil, and do not take more than 200 mg per day.
Another significant effect of modafinil is that it can reduce the concen-
trations of some oral contraceptives in the bloodstream. Women who wish
to take modafinil must be aware of this and discuss it with their g}^necolo-
gists so they can either adjust their oral contraceptive dose or consider other
methods of birth control.
As this book goes to press, a new medication called Prometa is being

aggressively marketed for the treatment of meth addiction. It is a propri-
etary combination of three medications that have been in use for a long
time, though never for the treatment of meth addiction. The foundation of
the treatment appears to rest on the use of flumazenil, a benzodiazepine
receptor blocker (i.e., an antidote for medications such as Valium and
Xanax). The theory behind this treatment is that flumazenil changes the
structure of the GABA receptors in brain cells, which become misshapen
from long-term drug use. By changing the shape of the GABA recep-
tor back to its original form, the hope is to decrease cravings for meth.
Flumazenil is administered in daily infusions by vein, in conjunction with
two other medications taken by mouth.

This medication regimen has been heavily marketed by the corporation
holding the proprietary rights to Prometa, through billboard campaigns as
well as solicitations of physicians. Aggressive marketing began long before
any reliable scientific evidence demonstrated that this treatment was effec-
tive, which has caused more worry than optimism in many physicians.
Recently, an open-label study —meaning a study in which all subjects
were given the drug —by Dr. Harold Urschel of Research Across America,
was completed showing that a remarkable 80 percent of people reported a
reduction of meth use. This figure is impressive, but consider the powerful
effect of placebos (fake pills) when the person taking the placebo is in the
right frame of mind. The subjects in this particular study were likely des-
perate for an effective treatment after several prior failed medications or

therapies. They may have seen billboard advertisements for Prometa mak-
ing promises of a new drug-free life, and then received a dramatic treat-
ment intervention involving daily intravenous infusions. In other words,

the weight of psychological influence in this context is heavy.
While the aggressive marketing tactics for Prometa treatment have made
addiction specialists extremely wary, the theory behind the treatment is an
interesting one. However, it still needs rigorous scientific testing —which
means a study in which half of the subjects are randomly assigned to get a
placebo. This type of research is called a double-blind placebo-controlled

study, which is considered much more reliable in ascertaining the true
efficacy of a treatment. It shows how much of the benefit is due to the
drug regimen itself versus the psychological effects of aggressive marketing
and taking a dramatic drug treatment regimen.
PEOPLE WITH A "DUAL DIAGNOSIS' —

DEALING WITH ADDICTION AND DEPRESSION, ANXIETY,
OR OTHER PSYCHIATRIC PROBLEMS
"Dual diagnosis" is a term used to describe people who have a drug
addiction and another psychiatric illness, such as depression, anxiety, bipolar

disorder, or schizophrenia. In the past, addiction and other psychiatric ill-
nesses were often treated by separate medical specialists, but because each
illness affects the other so profoundly, addiction experts strongly advocate
treating both illnesses together.
If a person has a dual diagnosis, and one of the two illnesses is left
untreated, it is highly likely that both conditions will get worse. For exam-
ple, if meth addiction is not adequately treated, then continued crystal
use can trigger depression, bipolar mania, psychosis, obsessive-compulsive
thoughts and behaviors, panic attacks, and anxiety Meth is so powerful
that it can render antidepressant medication useless, and people who
already suffer from major depression may become even more vulnerable
to severe depression and suicide.
Conversely, an untreated psychiatric illness significantly increases the
risk of relapsing on drugs. For example, if a person in recovery who has
been sober for years becomes severely depressed and suicidal, she may
remember the times when she used meth and her mood instantly lifted.
In a moment of desperation, she could easily slip, and if she stopped using
crystal, she would become more depressed, so she is then locked into a
full relapse, unable to stop using crystal. Another example is a man with
bipolar mania. In his manic state, his confidence is overinflated and he
forgets all he has worked to learn about powerlessness. In addition, mania
almost completely eliminates his impulse control — not only is he grossly
inappropriate in public, but when the urge to use crystal enters his mind,
he may not be able to stop himself. Once he starts using meth, the drug
chemically magnifies the manic symptoms, and he spins out of control.
With the excessive dopamine released by crystal, he may be at even more
risk of a psychotic mania, with hallucinations and delusions. These are
only two of many examples that demonstrate how significantly addiction
and psychiatric illness can affect each other, and they underscore the
importance of treating both illnesses at the same time.
This section will review some basic psychiatric illnesses that commonly
occur with addiction and can significantly increase drug relapses, and
conversely, these illnesses can be worsened by meth use.
Major depression is a clinical state that includes low mood, among
several other symptoms. Depression or low mood can be experienced dif-
ferently by each individual. Some descriptions include sad, tearful, hope-

less, empty, bored, flat, guilty, and worthless. Mood symptoms may be so
distressing that the person feels suicidal because life is so painful. Along
with the emotional symptoms, there are physical symptoms, including dis-
turbed sleep (increased or decreased), low or restless energy, poor motiva-
tion and mental fatigue, changes in appetite (increased or decreased), poor
concentration, and a significantly decreased ability to experience pleasure.

Depression can follow an upsetting event, but it can also occur for no
apparent reason. The medical definition of major depression requires a
period of at least 2 weeks with these symptoms, but this time restriction is
arbitrary and even 7 to 10 days of these symptoms without any clear reason
to feel sad should prompt you to seek psychiatric treatment.
There are numerous antidepressants on the market, each affecting vari-
ous neurotransmitters and neuropeptides (small proteins that are active
in the brain), including dopamine, norepinephrine, and serotonin. These
neurotransmitters may help balance mood and decrease the anxiety that
may contribute to craving for all addicts, with or without a dual diagno-
sis. Studies with various antidepressants have had mixed results as far as
treating addiction. A recent study of nondepressed meth addicts treated
with sertraline (Zoloft) actually showed a dramatic increase in relapses in
those who were taking sertraline compared with people taking a placebo.
There are many theories to explain this surprising effect: the sertraline
may decrease the depression in a crash, so people are more likely to use;
the increased transmission in some serotonin fibers may block certain
dopamine signals, which could make addicts crave meth even more. There
are many more theories, but the answer remains a mystery for now. The
major lesson is that the neuropharmacology of addiction is complicated,
and people should be wary of taking a friend's psychiatric medications or
other supplements to try to protect their brains, when they use drugs. This
does not mean that antidepressants increase relapses in everyone —the
subjects were nondepressed addicts. When used in appropriate situa-
tions, treating clmically depressed people with effective antidepressants

can significantly reduce cravings for crystal that can actually be desperate
attempts for any relief in their mood, as illustrated in the example at the
beginning of this section.
Schizophrenia is a structural imbalance in the brain, with overactive
dopamine activity in certain areas and deficient dopamine activity in oth-
ers. This is one reason schizophrenics are at higher risk for cocaine and
crystal addiction —during their first experience with cocaine or crystal,
they unknowingly stumble upon a wonder drug that elevates dopamine

where it had been low and caused them to feel lifeless, unmotivated, and
empty. The reward they experience from crystal may be even more power-
ful than what nonschizophrenics feel. Unfortunately crystal also increases
dopamine activity in areas that are already overactive, making schizo-

phrenics even more psychotic, suffering more severe hallucinations and
delusions. Treating schizophrenia with the right medication significantly
reduces the risk of relapsing. Common medications include haloperidol
(Haldol), chlorpromazine (Thorazine), olanzapine (Zyprexa), risperidone
(Risperdal), ziprasidone (Geodon), and aripiprazole (Abilify).
Bipolar disorder is brain disorder in which a person experiences alternat-

ing periods of depression and overactivation, which can have a euphoric,
irritable, or anxious mood accompanied by increased energy, overinflated

self-esteem, and difficulty controlling impulses. Even without the extra
challenges of mania, the urge to use crystal is powerful and sometime
irresistible. When mania is also present, a biological loss of impulse con-
trol makes it almost impossible to resist the urge to use crystal. The most
extreme forms of bipolar disorder may seem obvious to most people (e.g.,
the stereotypical comedy representation of two men sharing a jail cell who
both believe they are Jesus); however, there are still a surprising number
of people who do not believe it is a medical illness, but rather a difficult
personality. In its milder forms, when mood swings are not as extreme, it
can be harder for people to accept that it is a biological illness. However,

studies show that indeed it is. Left untreated, bipolar illness is actually
toxic to the brain, leading to destruction of brain cells, which can be
seen on imaging studies of the brain. Because of the terrible effect it has
on people's lives (25 to 50 percent attempt suicide, and 1 1 percent suc-
ceed in killing themselves), its toxicity to the brain, and its strong impact
on addiction and relapsing, it is extremely important to treat it properly
with medication. Common treatments include mood stabilizers, such as
lithium (Lithobid, Eskalith); valproic acid and valproate (Depakene and

Depakote); carbamazepine (Tegretol); oxcarbazepine (Tegretol); lamotrig-
ine (Lamictal); as well as the newly developed atypical antipsychotics,
such as olanzapine, risperidone, ziprasidone, and aripiprazole.
:
PART
5
OTHER IMPORTANT AREAS
IN YOUR LIFE TO KEEP YOU
CLEAN AND SOBER
IdentifyMajor "Holes" in Your Life
That You May Fill with Crystal
Ob j ectives
• Learn about specific psychiatric conditions such as
social anxiety disorder, depression, and attention-deficit/
hyperactivity disorder, which can significantly increase
your risk of relapsing if they are left untreated.
• Consider how hard you work, how nnuch you expect

from yourself, and whether you have been using
crystal as a way to nnaintain unrealistic expectations.
• Review the concepts of "stress nnanagement." "nnod-

eration," and "acceptance," which are fundamental to
leading a happy life, as well as reducing cravings and

relapses.
• Examine your social circle and consider how your
friends may help you stay clean or how they may be
triggers that pull you back to drugs and using crys-
tal. When forced to end destructive relationships,
consider ways of dealing with loneliness and finding
a healthier circle of friends.
• Think about how crystal has affected your experienc-

es of sex and consider ways to relearn the pleasure
of sober sex.
SELF-ESTEEM
How Much Do You Realty Like Yourself?
Crystal made me confident, even fearless —something alcohol and

cocaine could never do. I felt validated through meth-infused sex. A few
hours of illusory intimacy were better than days of emptiness. Instead of
always being the best little boy in the world, I could run, if only for a few
hours at a time, with the fast crowd —the fabulous people.
— Eddie Young, quoted in "Living with [out] Crystal Meth,"
Positively Aware July/August 2005
,
OF crystal's appeals
ONE is its ability
to elevate self-confidence. While most

people would enjoy a boost in confidence, this effect can be particularly
compelling for people who have deep-seated feeHngs of low self-esteem.
If the only time you feel good about yourself iswhen you are high, then
meth seems like one of the few things in this world that make life seem
worth living. But there are many other reasons that you can feel good
about yourself. If you have low self-esteem, ignoring your core beliefs
about yourself by masking them with drugs will leave you constantly
needing more drugs to protect you from the pain that low self-esteem
causes. Semple and colleagues at the University of California at San
Diego conducted a study looking at 157 heterosexual male meth users
and found that negative self-perceptions strongly predicted the intensity
of their meth use and depression. Do you have a distorted, low self-image
that puts you at risk for relapsing?
How is your self-esteem?

What was your response to that question? Many people instantly
respond that they are fine and have no problem with how they see them-
selves. In fact, the more quickly you respond, "There's no problem," the
more likely you actually believe there is something wrong, but you are
trying desperately to protect yourself from it and deny it. Remember the
famous quote from Shakespeare when Queen Gertrude says to her son,
Hamlet, "The lady doth protest too much, methinks." The queen was quite
astute, in realizing that the woman in the play she was watching protested
so much because she was trying to hide something. (Unfortunately, she
was not astute enough to realize that the character in the play she was
watching was parodying her\) Similarly, all people are capable of respond-
ing this way when we try to convince ourselves and others that nothing is
wrong. An automatic positive response to the question "How is your self-
esteem?" doesn't allow you time even to consider the question with any
thought. A quick reply avoids taking the time to examine yourself and pos-
sibly seeing something that you don't line. On the other hand, if you took
a couple seconds to ponder the question before answering, your response
was probably closer to the truth.
Pretending that nothing is wrong seems like a reasonable way to avoid
negative feelings — if you say that everything is fine, eventually everything

will be fine, right? Indeed, having a positive self-image is healthy, as long
as it is truthful. However, using superficially positive images that only mask

your true feelings is dangerous because the negative thoughts are never
addressed, and since they remain unchallenged, they continue to lurk in
the back of your mind. Until you take the time to examine those thoughts,
you will never address them and make them better.
WHAT IS SELF-ESTEEM?
How DO YOU feel about yourself? As a child, what kind of person did you
imagine you would become? Have you become that person of your fanta-
sies? One way to conceptualize self-esteem is to measure how successfully
you lived up to your self-expectations. Low comes from the
self-esteem
disappointment of failing your expectations. Good self-esteem comes from
SELF-ESTEEM I I7I
making realistic expectations and feeling the satisfaction of meeting them,
or at least being satisfied with why you have not met them yet.
Perhaps you have not wed the prince charming of your childhood dreams
because you were busy pursuing a promising but demanding and successful
career. Maybe you couldn't finish high school, against your parents' wishes,
because they died and your younger brothers and sisters needed you to earn
money to feed and shelter them. Perhaps as a child you had fantasies of
becoming a professional basketball player, but you grew to be only five and
a half feet tall. If childhood fantasies never turned into reality, is it because
you truly are a failure, or is this just where life ended up taking you, while
you deal with life in the best way you can?
WHERE DO EXPECTATIONS COME FROM?

Though many of us try to be open-minded, as hard as we try not to
make assumptions, to accept people just as they are, and to accept our
— —
own situations our lot in life it is a natural human process to form
expectations. We have expectations about ever^^thing — ourselves, other
people, common occurrences, such as the fact that summer should bring
with it warmer weather. In many instances, they are helpful: when we
are expected to attain certain level of performance at work; it helps keep
us motivated and productive. The problem arises when expectations are
unrealistic — if they are impossible to meet, then they are guaranteed to
cause disappointment. There are three ways to deal with this: (1) change
our expectations to make them more realistic; (2) feel intense disappoint-
ment but continue to have the same unrealistic expectations, which likely
leads to further disappointment; or (3) take extreme measures to meet the

expectations. Option 1 ,
trying to keep your perspective in line with reality,
is the healthiest. Options 2 and 3 are dangerous because they are stressful
and unrealistic, and can lead to drug relapses. For example, if you hold
on to the same expectation, which you repeatedly fail to meet, you may
treat the disappointment with drugs, rather than change the source, which
is the distorted expectation. In the third example, if you try to take extreme
measures to meet the unrealistic expectation, such as trying to meet an
impossible deadline, then you may resort to drugs like crystal to accom-
plish this. Only the first option, making your expectations more realistic,
will help you in a healthy and long-lasting way.

—
Many of our expectations —of ourselves, of others, and of situations

are based on similar experiences from our recent past that help us to
assess whatever is happening moment. Here's an example: 'There

at the
are hundreds of people on the subway platform. I haven't seen it this

crowded here since there was a major breakdown in the tracks. I bet the
subway system is having trouble, and I don't expect I'll make it to my
appointment on time." However, we also hold expectations of ourselves or
others without such an obvdous basis — for example, they could result from
distant, buried experiences from long ago, childhood fantasies of how we
wished things to be, traumatizing childhood disappointments that our
minds tr\' to protect us from ever experiencing again. Expectations based
on distant experiences and memories are extremely powerful because, in
most cases, we are not entirely aware of why we have them. Perhaps this
is because they are rooted in experiences stored so deeply in our minds

that they feel like "unquestionable realities, " and perhaps they are difficult
to question because we aren't aware of the reasons to challenge. Even

when the expectations are unrealistic and cause unhappiness, we often
simply accept them. Consider for example, a wealthy businessman who
is never satisfied with his company and is constantly driven to make more
money. Another case is a best-selling writer who, despite excellent re\dews
and record-breaking book sales, has a burning need to produce something
better. If you speak with her, you can see her creative enthusiasm, but you
can feel that something else is pushing her, that there is something she is
trying to prove to herself. These are not unusual examples. In fact, they
are quite common illustrations of how much of our beha\dor is influenced
by these mysterious self-expectations.
Most of our expectations, both conscious and unconscious, are shaped by
our earliest life experiences. Like sponges, babies and small children absorb
everything from their environment. During this early stage of human devel-
opment, babies and children begin to form a rudimentary understanding
of good versus bad, and the actions and words of the people around them
help them figure out what falls into each category. Along with a general
concept of right and wrong, children have both internal fantasies — their
own innate desires —and external messages —encouragements, demands,

and explicit expectations that others tell them — what ihey should
of be, as
well as what they should never be.

For example, a mother tells her little boy, "Your father and your grand-
"
SELF-ESTEEM I 175
father worked so hard to build the family business, and when you're an
adult, you'll take over the company! We'll be so proud of you! You know,
that company is what this family is built on, and it's very important for you
to keep it going when you're older and it's your turn." Another message that
used to be commonly heard, both at home and in some school home eco-
nomic classes was, "If you want to be a happy woman, you have to be able
to cook well for your husband, so make sure you learn how to cook!" More
subtle messages that children pick up are statements as simple as: "Don't
do that! What will others think?" The majority of messages children hear
are attached to strong emotions, as well as judgments of right and wrong:
the little boy feels pressure to take over the family business because any
desire to do anything else would disappoint his beloved parents, even if
he were not interested in the company at all; the girl hears a message that
her happiness is determined by marrying a man and then doing whatever
it takes to please him — a compelling message for any human being who
wants to be happy. Even as we grow older, develop our own interests, and
have rational ideas of what would best make us happy, those childhood
messages, so heavily weighted with our earliest beliefs about what deter-
mines happiness or sadness, quietly linger and affect how we feel about
ourselves and what we expect ourselves to be and to do.
The most significant role models for children are usually their parents.
To some degree, we all inherit some of our parents' expectations, whether

we agree with them or not. A common experience is for a boy to say, "When
I grow up, I'll never act like Dad!" Then, one day in his adult years, he
hears himself scolding his own children and says, "Did I just say that? I'm
acting just like my father!

Even if children angrily disagree with their parents, they unknowingly
internalize many of their parents' expectations. Despite the rebellious atti-
tude of many teenagers who are trying to develop a sense of independence,
all humans have some innate desire to please their parents. This is true
even if they are only aware of disagreeing with their parents and feeling
anger toward them.
What did your parents expect of you? Did they expect you to go to
college and become a wealthy businessman? Did they expect you to get
married, imagining themselves happily surrounded by the grandchildren

they expected you to have? These parental wishes may become yardsticks
that you unconsciously use to measure our own success or failure, as well
as your feelings of satisfaction or disappointment in whatever you do.

For gay men, internalized expectations of parents often become a tre-
mendous source of unconscious disappointment and self-loathing. All

children receive messages about sexuality constantly, through words from
their parents, friends, and teachers; from television shows and movies,
from watching people on the street; and even from simple magazine adver-
tisements and commercials. Many homophobic people say to gay people,
''Don't flaunt your sexuality in front of the whole world!" The reality is
that every television show that includes heterosexual people mentioning a
spouse, child, or potential love interest, a jewelry commercial that shows

a diamond engagement ring, or a travel brochure with a picture of a man
and woman holding hands on the beach — all of these are "flaunting" het-
erosexuality. Children are constantly bombarded by these messages that
tell them, "Life is supposed to culminate in a heterosexual relationship,
marriage, and children, and the ultimate goal in life is to continue the
family name." Even the most "out and proud" gay man may struggle with
a deeply hidden, disapproving "yardstick" that leaves him feeling that in
the end he still does not measure up.

Understanding your unconscious expectations is a long process, best
done with the help of an experienced therapist. However, the following

two exercises provide ways to start your self-exploration, and to see what
buried and hidden beliefs may still be affecting your behavior and your
self-esteem today
EXERCISE 12-1 PAREETAIi EXPECTATIONS i
I
t
PARENTS are the people with whom babies and small children have the
most social contact. Because children have a natural desire to please
their parents, their expectations are particularly compelling. Ask your-

I self the following questions about your parent's attitudes. Can you see
i
I any of them in how you judge yourself?
As a child, do you remember if your parents felt proud of you?

|
Disappointed? Satisfied? Ashamed? Frustrated? A combination of

SELF-ESTEEM I 175
different feelings? Do you remember any predominant feeling?

Were you ever confused about how your parents felt about you?
Did they ever give you confusing messages, such as, "Congratula-
tions for winning the silver medal! Too bad you couldn't get the
gold." Did you feel they were beaming with pride? Did you think
they were disappointed? How did you feel about your parents at
that moment? How did you feel about yourself?
m How far did your parents expect you to go in school?

tl Did your parents push you to get good grades? How hard? If they
did not push, did they care about grades or how well you did?
Did they focus on other things in your life that they thought were
more important? Did they not believe you were capable of doing
well? Did you feel that your parents generally weren't concerned
about you?
How did your parents react to your school performance? Were
they proud? Were they indifferent? Were they worried at times but
encouraging? Were they angry? Do you remember this ever affect-
ing how you felt about your intelligence or your own abilities?
Did your parents help you whenever you needed assistance,
or did they encourage you to be "strong" and to do things for
yourself? How did this make you feel? Abandoned or neglected?

Stronger and more capable? Weak, like a failure?
m Did your parents ever ask you about who you were dating? Were
they uninterested? Were they intrusive, asking a lot of questions
or giving a lot of advice to point you in "the right direction"? Did
they ever disapprove or seem disappointed? Were they open and

supportive? How did that affect your attitude toward your own
romantic and sexual feelings?
II Did your parents ever tell you what they wanted you to become
when you grew up? I
m What did your parents imagine your life would be like when you
reached age thirty?
I
m Did your parents ever say they wanted grandchildren? As a child, I
did you ever imagine yourself as an adult with children? If you

answered yes, why do you think that as a child, you were already
J
thinking about having a baby? What was the motivation behind

that fantasy?
When your parents innagined their own later years in life, how did
you fit into their picture?
EXERCISE 12-2 SOCIETY'S EXPECTATIONS
IN addition to the influence of parents, children continue to learn social
norms as they grow up, absorbing general society's ideas as if they were
axiomatic truths. As adults, we are taught to think rationally, and most be-
lieve that logic governs our behavior more than the older ideas we picked
up during childhood. However, consider the phenomenon of the dreaded

high school reunion. The purpose of reunions is enjoyment, but many, if not
most, people attend them feeling excitement that is mixed with feelings of
anxiety and dread. Reunions are unusual occasions when old, uncomfort-
able beliefs about former classmates' judgments and expectations come
back to the surface. Many feel a pressure to prove their success, that they
were able to meet or exceed their classmates' expectations. Why does a
regular job feel acceptable at other times, but at a reunion it might feel
like a source of shame? The influence of other people's expectations may
have seemed dead and buried, but at a reunion, you realize that they have
always stayed with you, and only now are they so apparent.
What were the expectations that you learned from your peers when you
were growing up? Answer these questions to clarify what they might be.
^ What did most of the other kids like to do in elementary school?

What games did they play? In junior high and high school, what
were most people interested in? Sports? Hanging out at the mall?
^
Playing video games? Dating? Going to parties and drinking alco-
hoi or doing drugs?
I
I What did you like to do in high school— were they the same things
I as everyone else, or were they different? If they were the same,
how did you feel about that? If they were different, how did that
SELF-ESTEEM I
make you feel? Did the differences have any effect on how you
saw yourself? Did you feel smarter, dumber, prettier, uglier, less
popular, or an outcast? Did you wish you could fit in better or did
your differences make you determined to be the opposite, so off-
beat that you could feel cool in your own way and avoid the worry
about being like everyone else?
How did other kids in school treat you? Were you a popular student
with a large following? Did this make you feel confident and free
or did you feel pressure to behave a certain way because you
were afraid of losing people's respect? Were you somewhere in
the middle, with a group of nice friends but wanting to be with the
more popular kids, striving to look and act like them and hoping to
one day be one of them? Were you mistreated by your classmates,

rejected for being different and not allowed to be part of the group?
How did your classmates' treatment make you feel about yourself?
Did most of your classmates graduate from high school? Was it
rare that kids in your school attended college? Did most of your
classmates go to college or graduate school? How far did you go
in school, and how did this make you feel about yourself?
What kinds of jobs and lives did your classmates imagine for
themselves? Did they want to stay in their hometown and get any
job that would pay the bills? Did they want to move away, get a
particular job, or want to make a tremendous amount of money?

Did they plan to marry or have children? When you were in school
together, how did your own hopes and dreams compare to your
classmates'? Were they the same? If they were different, how did
that make you feel? Did you talk to your classmates about how
different your plans were? If not, what thoughts and feelings held
you back?
What are your classmates doing now? Are they working? What
kinds of jobs do they have? Are they single, married, or divorced?
Are they gay or straight? Did they have children?

What was the "macho" expectation for guys in high school? What
was the "feminine" expectation for the girls?
In your class, how did you fit in?

After completing exercises 12-1 and 12-2, consider the expectations

of your parents and classmates and the many ways in which those expec-
tations were communicated to you. How closely does your life compare
to the expectations of your parents and classmates? Going through the
exercise, along with other people's expectations, think about your reac-
tions to them —how they made you feel about them and yourself. Did you
feel content and satisfied, or did you feel different? Did you want to fit in
more or to please your parents better? Did you try to free yourself of those
expectations and take a completely different path? These two exercises
are not in-depth explorations of your personality, but they help you to un-
derstand that some of your self-expectations are from people, places, and
times outside of your immediate awareness. Knowing this, you can search
beyond the surface appearance of your motivations to look at what they
really are. Regardless of your job success, number of sexual conquests,
accumulated wealth, or whatever you have achieved, according to the
deeper self-expectations which you may still hold, are you a success or a
disappointment? Unconscious expectations can be harsh, irrational, and

unrealistic. Therefore, it is important to identify any hidden expectations
you hold yourself to and understand where the expectations come from
and the reasoning behind them. Knowing these things, you can assess
whether they are appropriate or whether they need to be revised.
Ultimately, self-acceptance and self-satisfaction determine happiness.
The less you accept yourself, the unhappier you are. Drugs offer a tem-
porary way to address disappointments because they artificially alter the
way you feel about yourself. "Downers," such as alcohol or heroin, make
people care less or feel numb to disappointment. Stimulants, such as
crystal and cocaine, can pump up feelings of self-worth, allowing users a
temporary' sense of confidence, power, and attractiveness. For some, using
may be the only time when they genuinely feel good about themselves.
Unfortunately, these positive feelings are artificial and last only as long
as the drug high because there is no fundamental change in the cause of
low self-esteem. Many people simply try more crystal to feel better again,
digging themselves deeper and deeper into addiction. The better way to
address bad feelings, as well as to avoid relapsing, is to develop a stronger,
more positive sense of self.

SELF-ESTEEM I 179
WHAT CAN DO TO IMPROVE MY SELF-ESTEEM?

I
Self-esteem is a deep-seated character trait. It took your entire life to
evolve into what it is now. That is why quick-fix remedies, such as repeat-
ing the mantra "I love myself!" or simply telling yourself, ''Everything's
fine!" do not really work. They may give you a temporary boost, and remind
you that you should love yourself and feel worthwhile, but they do little to
actually change how you see yourself. If you never address those nagging,
hidden self-expectations, they will continue to haunt you and make you
feel inadequate.
Psychotherapy can make profound and lasting improvements in your
self-esteem, but the process can be long, and ongoing therapy may not
be a realistic option for you. There are also cognitive strategies that take
a different approach, which is still effective for many and can also have
long-lasting effects.
The following exercise works on the belief that disappointment results

from not fulfillmg your self expectations. If your expectations are unreal-
istic, then you are bound for disappointment. The exercise, divided into
five parts, clarifies what your expectations are, compares them to your
real life situation, and examines why they do or do not match. Adjust your
expectations so they are realistic, and then you can assess how well you've
miCt them. If you still haven't met these revised expectations, at least these
expectations are logically constructed, and you can think of rational ways
to meet your goals.
EXERCISE 12-3a EXPECTATIONS
LIST expectations you currently have or used to have about your own life
» in the following areas. Include rational expectations, but also include
any childhood fantasies you may have had (e.g., I wanted to be an as-
tronaut; I used to dream about becoming Miss America; want I to be the
next Donald Trump; I wanted to be the first black, female president of
I the United States).
Education
Appearance
Occupation
Income
Relationships
Other miscellaneous areas

SELF-ESTEEM I 181
EXERCISE 12-3b REALITY
HOW does your reality compare to the expectations in exercise 12-3a?

What have you achieved in the following areas? Did you meet, fail, or
surpass those expectations?
'
Education
Appearance
Occupation
Income
Friendships
Romantic relationships

EXERCISE 12-3C EXPLAIN THE DIFPEHENCE

I
IF certain aspects of your life did not turn out as you had expected, what
are the reasons? Here are some possible explanations: Did you have
poor grades in school because you never actually gave it a good fry?
Were you afraid that if you tried and failed, then this would prove that you
were undeniably stupid? Did you try a particular job but, even with your
best efforts, you couldn't do it? Did other job opportunities come up in
life, which you chose instead because they seemed more promising? Did
your interests change over time, and you decided to pursue something
more interesting while your parents" expectations remained the same?
Were there unavoidable reasons for not being able to fulfill the expecta-
tions? For example, if telling your family and classmates you were gay
caused violent reactions and rejection, did that affect your performance
in school or make you rebel against your family and peers and pursue
the opposite of their expectations? Did angry or abusive parents kick you
out of the house and take away the financial support that would have
helped you finish school? Did you wish to be a beautiful, blonde-haired
woman with blue eyes, but being in an ethnic minority and having black
hair and brown eyes, were you never able to see yourself as pretty? Did
you think you wanted to be a doctor because your parents and all your
brothers and sisters were physicians, but biology bored you and the sight
of blood made you faint?
in each category, try to explain why any of your original expectations

did not match how your life actually turned out.
Education
Appearance
SELF-ESTEEM I
Occupation
Income
Friendships
Romantic relationships

EXERCISE 12-3d REVISE YOUR EXPECTATIONS
CONSIDER the reasons you gave in exercise 12-3c for not meeting your
expectations. Are they justifiable? Are there areas that you think you
should still work on? Consider your life experiences; your knowledge
about yourself, your interests, and your abilities; the challenges you
face each day; and the other unavoidable circumstances of your life.
With these in mind, go through the same categories and write realistic
expectations for yourself in each.
Education
Appearance
Occupation
Income
Relationships

SELF-ESTEEM I 185
EXERCISE 12-3e HOW TO WORK ON AREAS THAT REAILY

NEED IMPROVEMENT
I
THERE may be some expectations that you find still make sense, and
though you haven't met them, you wish you could., With a logical un-
derstanding of your expectations, your abilities, and your challenges,
what specific things can you do to meet those expectations? If you always
wanted to get a college degree, can you return to school or take night
classes while working? Are there ways that you can advance in your ca-
reer? Have you fully investigated job opportunities, talked with a career
counselor, or contacted a headhunter? If you are dissatisfied with your

appearance, are there ways that you can improve the body you have in a
healthy way? In summary, are there realistic ways to reach the goals you
have set for yourself? If you have unmet expectations that are achiev-
able, then making a concrete plan and seeing that they are attainable
will give you a sense of hopefulness and control, and you will already be
on your way toward higher self-esteem.
Education
Appearance
Occupation
Income
Relationships
This five-part exercise encourages you to think about self-expectations in

a systematic, organized way; confronts you with difficult self-perceptions;
and helps correct "cognitive distortions, ' which are unrealistic thoughts
that you held on to, silently affecting the way you experience yourself and
the world around you.
Digging up old and buried expectations and addressing them directly,
rather than hiding from them, will help you improve your self-esteem. If
you find that your self-esteem is extremely low, it may take a long time to
raise, but this exercise can serve as a springboard for more intensive work
in psychotherapy. Working on yourself over the long term doesn't sound as
easy or as attractive as drugs, but it will be far more rewarding as you begin
to feel truly happy with yourself. Repeat this exercise from time to time
to see if your answers to any of these questions have changed. You may be
surprised at how your answers change as your self-esteem rises.
Reaching a Better Understanding of Himself BHIAN's STORY
In addition to attending CMA meetings. Brian started to see a psy-
chiatrist who explored his self-esteenn issues and deep-seated notions
of low self-worth. He had thought he was comfortable with being gay— he

had come out to his family and all his friends in his midtwenties, and
outside of work, he considered himself "comfortable" with his sexual-
ity. However. Brian started to see how he quietly harbored feelings of
shame about his sexual orientation, guilt for disappointing his parents,
SELF-ESTEEM I 18?
and anger and hatred toward hinnself. Gradually he understood that he
was angry and disappointed at his inability to be what his parents wanted,
so he tried to show them, as well as hinnself, that he was still worthwhile
by beconning a successful attorney. "Was that the fire that kept me fueled
|
to sit through all those boring law-school lectures I hated so much';*" he

|
asked himself. He realized that no amount of work was going to address |
his parents' view of homosexuality— if that were to change, he'd have to f
tackle it in a different way that would address his real dissatisfaction.
Brian also found that some of his anger mimicked the hatred toward gays
that he witnessed growing up. He had always thought that joking with his gay
friends about effeminate men and casually using works such as "queen."
"queer." "fag," and "Mary." were ways of accepting his sexual orientation. But
they were also ways that he held on to the homophobia he had learned as a
child. Sometimes his anger became an intense, irrational rage toward himself
that he hadn't completely understood: at times he thought to himself. "How

could I let myself be such a pathetic loser'?'" despite his hard work, successful
career, and good looks. Suddenly he recalled a time in high school when he
felt such self-loathing and despair because of being gay that he contemplated
different ways to kill himself.
Accepting himself as a gay man was not as simple as admitting that
he was gay, and Brian found that he had not been as comfortable with his
sexual orientation as he had thought. All of the negative feelings and self-
expectations he inherited from others contradicted his natural attraction
and desire to be with men. This made sex and relationships terribly
confusing because despite knowing that he wanted to be with men, his
pleasure was always tainted by unclear bad feelings. \.
Brian gradually worked on improving these parts of his self-esteem, and
he was able to feel better about himself— not in a temporary drug-induced

way, but in a long-lasting, fundamental understanding of himself. He didn't
need crystal to help him with that aspect of his life anymore. Brian still had
urges to use and had a few slips. But he stuck with his treatment program
and created a network of sober gay professionals he could connect with in
ways other than drugs and circuit parties. He felt connected, accepted, and
validated, both as a gay man and as a human being. At the time of this writing,
it has been two years and five months since Brian has used crystal.
n
SOCIAL ANXIETY:
When It's Difficult to FeeL ComfortabLe
Around Other People
SOME PEOPLE USE crystal to help them

manage social situations because of its
positive effect on their confidence. Quiet people who are usually wall-
flowers at parties may start to feel talkative, engaging, attractive, power-
ful, and desirable. Having always felt left out, they finally see themselves
able to participate in the world, at least when they are using meth.
Social anxiety is common. Most frequently, it is simple shyness,
quite
feeling timid, and slow to warm up to others. It is usually associated with
some anxious belief that others will see the person in a bad way. Shy
people are quiet with strangers, but usually they can still function well
inlife. More extreme social anxiety is considered a disorder called social
phobia or social anxiety disorder. When shyness reaches the level of

social phobia, the fear of embarrassment becomes so intense that it is dif-
ficult or impossible to face people and get through day-to-day life. These
people withdraw or rarely go out of the house because their anxiety is so
disabling. This doesn't mean they don't want to be around others —on the
contrary, they want desperately to interact with people. However, their
SOCIAL ANXIETY I 189
fear imprisons them in their loneliness, and they feel miserable. While
meeting all of the criteria for social phobia may be extreme, a great number
of people suffer from a lesser degree of social anxiety or shyness that still
significantly worsens their quality of life.
The DSM-IV criteria for social phobia are listed in table 13-1:
TABLE 13-1
DSM-IY Criteria for Social Phobia

SOCIAL PHOBIA
< A. A marked and persistent fear of one or nnore social and performance situations in
^
which the person is exposed to unfamiliar people or to possible scrutiny by others.
: The individual fears that he or she will act in a way (or show symptoms) that
anxiety
^
will be humiliating or embarrassing. Note: In children, there must be evidence of
I
the capacity for age-appropriate social relationships with familiar people and the
anxiety must occur in peer settings, not just in interactions with adults.
B. Exposure to the feared social situation almost invariably provokes anxiety, which
;
may take the form of a situationally bound or predisposed Panic Attack. Note: In
^
children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking
;
from social situations with unfamiliar people.
I'
C. The person recognizes that the fear is excessive or unreasonable. Note: In children.
I
this feature may be absent.
j
D. The feared social or performance situations are avoided or else are endured with
i
intense anxiety or distress.
1 E. The avoidance, anxious anticipation, or distress in the feared social or performance
situation(s) interferes significantly with the persons normal routine, occupational
(academic) functioning, or social activities or relationships, or there is marked
distress about having the phobia. j
F. In individuals under age 18 years, the duration is at least 6 months.

G. The fear or avoidance is not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition and is not bet-
ter accounted for by another mental disorder (e.g.. Panic Disorder With or Without
Agoraphobia. Separation Anxiety Disorder. Body Dysmorphic Disorder, a Pervasive
I
Developmental Disorder, or Schizoid Personality Disorder).

H. If a general medical condition or another mental disorder is present, the fear J
in Criterion A is unrelated to it. e.g.. the fear is not of Stuttering, trembling in
Parkinson's disease, or exhibiting abnormal eating behavior in Anorexia Nervosa

or Bulimia Nervosa |
Reprinted with permission from the Diagnostic and Statistical Manual of Mental I
Disorders, Fourth Edition. Text Revision (Copyright 2000). American Psychiatric \
Association. I
Whether you meet full criteria for social phobia or have a significant
degree of social anxiety, you may be using crystal as a way to cope — ^you Ve
found something that makes you feel and function better when you use
it. But the effect is only temporary It doesn't change the person you are
or your fundamental fears of what people think of you. You know from
experience that once the high disappears, you will return to the same shy
person you were before. You may feel even worse during the crash after
using. It eventually becomes a trap, because you see that you can func-
tion well socially and feel acceptable, but the only way to keep this up is
to keep using.
One way to address problems with socializing that is healthier and
longer-lasting than using crystal is to examine your self-esteem (see chap-
ter 12) and change the negative core feelings that you have about yourself.
Most of your shyness is probably based on false beliefs about yourself and
your fear of how other people see you. An anxious reaction to these beliefs
turns it into a self-fulfilling prophecy. You think you appear awkward, you
become increasingly nervous, and when forced to speak, you may be so
overwhelmed by anxiety that your voice trembles, you become red or cov-
ered in sweat, or you blurt out something strange which you would never
have said under normal circumstances —you are too distracted by your
anxiety to think clearly and say what you mean. You aren't a fool, but if you
allow it, your fear will convince you that you are.
Consider an Olympic gymnast who has to mentally focus on her take-

off, her body position at every moment of her routine, and her landing.
Distraction by the smallest thing can throw off her performance, and if she
is distracted by overwhelming anxiety, her performance will be terrible.
Think of the boxers who stare into the television camera or at their
opponents and growl, saying that they are going to destroy the other fighter.
Both fighters say the same thing, though it is impossible that they will both
win. Some of this is bravado and showmanship —they need the fans, the
ratings, and the ticket sales. But much of this is to prepare themselves
mentally. They need to elevate their self-esteem, and they cannot allow
themselves to be distracted by fear. In the same way, if they can scare
their opponents and can fill them with self-doubt, the opponent will not
perform as well.
Self-perception has a tremendous effect on a person's performance.
even if that person is truly skilled. If you use crystal to artificially ease your
social discomfort, you will never address how you actually see yourself,
and without the drugs, your negative self-perception will always be there,
making you uncomfortable around other people. On the other hand, if
you directly address your fears and reactions, then you give your true
strengths a chance to shine. This becomes a self-fulfilling prophecy, as
well. The more you see yourself socially effective without drugs, the more
you believe in yourself, and the more your confidence shows, and the
better you function in social situations. And this no drug — this is a real
change in you.
i!
WHAT CAN YOU DO TO LOWER SOCIAL ANXIETY?

i
Improve Your Self-Esteem
j!
The first step in lowering social anxiety is to examine your real thoughts
and beliefs about yourself. How do you see yourself? Where do those
thoughts and beliefs come from? Are they based in reality? See chapter
12 for a detailed discussion on this topic and exercises on how to improve
your self-esteem.
Practice Your Social Skills
One of the most basic and most effective treatments for social anxiety
is cognitive-behavioral therapy (CBT). CBT involves intensive work

and it is extremely challenging. Like training for an Olympic competition,
CBT is a long road of pushing yourself through uncomfortable exercises,
with small, incremental gains at any one point. However, the overall gain
is tremendous and long-lasting.
The cognitive part of "cognitive-behavioral therapy" examines the way

you think about yourself. Is your view distorted for some reason? Gather
some data. Ask other people how they see you, especially people who know
you well. Strangers or superficial acquaintances may be more familiar with
the shy you, but people who know you well, such as your family and friends,
know what you are like when you are not anxious. Exercises 3- through 1 1
13-3 help you to find any cognitive distortions and correct them.
EXERCISE 13-1 HOW DO YOU PERCEIVE YOURSELF

I
IN SOCIAIi SITUATIONS?
EVEN if you feel fine about yourself when you are alone, your comfort and
confidence nnay evaporate when other people are around you. Answer the
following questions about how you imagine you appear in social settings,
such as parties or office meetings. Even if your fantasies seem irrational,
try to be as honest as possible about your thoughts and fears (e.g., "Every-
one is looking at me" or "I seem so boring and nobody cares what I have
to say"). Use these questions to help you consider different ways you may
view yourself, and feel free to include any areas not listed.
How do you imagine other people see you?
How do you imagine you sound when you talk in a group? Do you seem
intelligent? Do you seem nervous? Do you seem as if you know what you
are talking about? Do you seem stupid or silly?
Do you ever say anything interesting? Are you concerned that people are
bored or annoyed when you speak?
Do you think that anyone has ever been attracted to you? Why or why
not?
What are things that other people may lil<e about you?
Do you think there are any other positive things that people think about
you when you talk with them?
Do you think there are any other negative things that people think about
you when you talk with them?
EXERCISE 13-2 WHAT ARE MY REAL STRENGTHS

AND WEAKNESSES AND HOW DO OTHER
I
j
PEOPLE ACTUAIilY SEE ME?
ASK the following questions of family members and friends with whom
you are comfortable and familiar These are the same questions as in ex-
ercise 13-1, but they examine an outsider's perspective.
How do I look to you?
How do I sound when I talk to you? Do I seem nervous? Do seem as

I if I
know what am I talking about? Do seem stupid or

I silly?
Do ever say anything interesting?

I
Do you know if anyone has ever been attracted to me?
What are things that you like about me?
Is there anything else positive that you notice when we are together?
Is there anything negative that you notice when we are together?

EXERCISE 13-3 IDENTIFYING COCTITIVE DISTORTIONS
WERE there any differences between what you imagined about yourself
in exercise 13-1 and what your fannily and friends thought in exercise
13-2? This will help you to understand how different your fears can be
j
from reality. These differences are called cognitive distortions, and |
the distortions need to be corrected. Simply knowing that the fears are I
1 irrational is not enough to make them go away. However, with a list of

^
t
cognitive distortions to work on, you have a focus and can address your
fears constructively.
For each of the differences that you found in exercises 13-1 and 13-2,
write the following statement:
^ I fear that when I am around people, others will see me as
However, the reality is that people have seen me as

EXERCISE 13-4 CORRECTINa COOTITIYE DISTORTIONS-

A BEHAVIORAIi APPROACH
ONCE you know the false assumptions that you make, use them in this
technique of behavior therapy.*

Pick a specific fear identified in your list of cognitive distortions in
exercise 13-3, e.g., "When I approach strangers and introduce myself,

they think that I sound stupid." Start with one of your less challenging
fears. Your task will be to do this specific act at least ten times in one
day. Repeat this exercise daily for five days— this means repeating the
act a total of at least fifty times. Make the task simple and quick. For ex-
ample, if you are in a party, go up to ten different people you don't know,
casually introduce yourself, and say, "Hello, my name is Pat Smith. Nice
to meet you." Keep the interaction brief and say something positive and
simple, such as, "This is a great party, isn't it?" Have a standard exit line,
such as "Oh, no! Please excuse me, I need to find my friend Jamie. It was
a pleasure meeting you." and move on. Remember, in this exercise, your
only goal is to say hello, not to make new friends. Limit your interactions,
as you are concentrating on overcoming your anxiety from one specific
behavior— approaching strangers and saying hello. If you linger and try
to interact further, other sources of anxiety may arise, and the benefit of
the exercise is lost.
This technique is called exposure with response prevention (ERP).

The more you expose yourself to a fearful situation, the less sensitive
you become to it. After each exposure, you will find that your level of
anxiety decreases. Optimally, you should do these exposures in quick
succession for your mind and body to learn from the experiences. If you
do this exercise only once every two weeks, every day that you do not do
the exercise, you reexperience your old fearful reaction, and you relearn
your fear response. The next time you do the exercise two weeks later, it
may feel like you are starting from scratch.
*Behavior therapy is an effective method of changing emotional responses by

repeatedly exposing a person to something to elicit a specific response. In the
case of anxiety, behavior therapy repeatedly exposes a person to something he
or she fears and trains the person's body to stop having the biological responses
; of anxiety.
Expect that the first few times you do this exercise, your anxiety will be
high, and indeed you may appear a little awkward to others. Nonethe-
less, continue to repeat the exercise. Remind yourself that even if you
feel stupid at first, it is not because you are stupid— it is because you
don't feel confident. The more times you repeat the behavior, the clearer
it will become that even if you blunder, nothing terrible actually hap-
pens. Intellectually you learn this through observing yourself. Biologi-
cally, your body is unable to keep up a sustained state of anxiety, so if
done in rapid succession, your body's anxiety response will decrease.
Both mentally and physically, you become desensitized to your fear.
The first few times you do this exercise, concentrate solely on com-
pleting the task. After a few repetitions, if your anxiety has decreased
somewhat, you will feel less overwhelmed each time you expose yourself
to the situation. At that point, you can observe yourself and the people
around you, and you are better able to compare your cognitive distor-
tions to what actually happens when you do the exercise. In our example
of approaching people to say hello, take note of the following:
1. What was the other person's response to you? Was the response
what you had imagined?
2. How do you think you seemed to the other person?
3. How uncomfortable or anxious was the situation for you?
As you continue the exercise, continue to gather data about your cog-
nitive assumptions and distortions.
This is a labor-intensive exercise, much more that doing a bump of
crystal. However, it pays off tremendously because it is effective and

the improvement endures— and there is no crash afterward! If anything,
some people feel a high from the confidence and rush of accomplish-
ment. In addition, this exercise teaches you a way to deal with anxiety
of any type, demonstrating that you can overcome it yourself. If you are
persistent with this exercise, you will gradually start to incorporate this
method of repeated exposure and desensitization into other aspects of

your life without even noticing it, and you may develop your own auto-
matic ERP techniques to handle anxiety.
Medications
If behavioral techniques are not possible because you are so anxious

that you are unable to try exercise 1 3-4, then your social anxiety may be |
extreme enough to require medication. The most effective medications
for this type of anxiety are selective serotonin-reuptake inhibitors

(SSRIs). Serotonin is involved in many functions of the brain, including
cognition (thinking and memory), mood, impulsivity, and different aspects
of motivation. Studies of baboons, which have strict hierarchies, show that
the more dominant baboons have higher brain levels of serotonin, while
serotonin levels in brains of those at the bottom of the chain were the low-
est. It is not clear if serotonin causes dominance or, conversely, if social
success increases brain levels of serotonin. Regardless, numerous studies

show the relationship between serotonin and social behavior, and sero-
tonin-related medications have been investigated and used successfully for
people with social anxiety. Methylenedioxymethamphetamine (MDMA),

commonly known as Ecstasy, is an extremely powerful serotonin agent,
which induces intense feelings of social bonding and closeness. Likely this
is one of its greatest appeals for marginalized or nonmainstream teens who

often go to rave parties, as well as gay men at discos and circuit parties.
Both groups struggle with experiences of social rejection, and the social
bonding effect of Ecstasy can feel tremendously healing. Unfortunately,

Ecstasy is also toxic to the brain, and the effect on social connections is
short-lived.
SSRIs affect serotonin in a gentler nontoxic manner, and they have

been found to be extremely effective at decreasing social anxiety. Ask a
psychiatrist to see if this medication is appropriate for you. Each brand of
SSRI has its own unique side-effect profile, so there may be a process of
trial-and-error to determine which is best for you. Also, initial side effects
take some time to resolve, while the therapeutic effects begin after sev-
eral weeks — this is the price for taking a medication that is effective but
extremely safe and nonaddictive. Knowing this beforehand may decrease

the frustration of finding the right medication. But the wait is worth it.
Psychiatric medications should always he taken under the direction and

supervision of a physician familiar with them.
Another major class of medication that helps with social anxiety is sero-
tonin-norepinephrine reuptake inhibitors (SNRIs). They increase
levels of both serotonin and norepinephrine, and they may be an effective
alternative to SSRIs, if you can't find one that works well for you.
Taking psychiatric medications for social anxiety does not necessarily

mean you will need to take them for the rest of your life. If you work closely
with a therapist, then medications may be only a temporary part of your
treatment. Optimally, you should work with a therapist to address social
anxiety, whether or not you take meds. However, if you do take meds, a
therapist will monitor your feelings closely during treatment as you do
exercises such as those in this chapter to work on the core psychological
beliefs behind your anxiety. Watch yourself interacting with others effec-
tively and store these images in your mind, internalizing observations of
yourself as a socially competent person.
If you decide to stop medication, taper off in small increments. Unlike
with crystal, cocaine, and Ecstasy, you may not notice the loss of effect
for several weeks or months with each decrease in dose. If social anxiety
returns, the small decrease in your dose should allow only a small increase
in anxiety, and this less intense anxiety will be easier to address with
behavioral exercises, such as exercise 13-4. As you become less anxious
again, try another small decrease in medication, and repeat the behavioral
exercises. Eventually you may find that you do not require medications at
all. Medications should always be gradually tapered, to prevent any pos-

sible withdrawal discomfort that occasionally occurs. Symptoms can range
from mild body aches, dizziness, and fatigue, to moodiness or spontaneous
crying. Again, medications should always he taken under the supervision of
an experienced physician.
An important class of medications to mention is the benzodiazepines,
including medications such as VaHum, Xanax, Klonopin, and Ativan. These
medications treat anxiety quickly. They were discussed as one of several
ways to help with the extreme distress some people feel during a crash.
However, benzodiazepines are addictive, particularly if you already have an
addiction. In the crystal detox protocol outlined in chapter 9, they are used
with extreme caution and given only in a small, limited amount. If you use
them regularly, they can increase your risk of relapsing onto crystal, even
though they have a completely different effect than meth. An important
rule of thumb is to avoid taking any potentially addictive drug. Remind
yourself that you are taking medications, practicing cognitive-behavioral
exercises, and treating anxiety in order to treat your crystal addiction. You
do not want tomake your addiction worse, and you certainly don't want
to pick up a new one.
A BRIEF NOTE ABOUT PSYCHODYNAMIC PSYCHOTHERAPY

Psychodynamic psychotherapy is based on the principles of psycho-
analysis, the school of psychotherapy most popularly associated with
Sigmund Freud. Encouraging the patient to think by free association, psy-
chodynamic therapy delves deeply into your personality, uncovering what
may lie in the unconscious (unaware) mind that influences your behavior.
It focuses on three aspects at understanding you: (1) your present life;
(2) the distant past from childhood, which forms the template for how
people experience the world as adults; and (3) the relationship between
the patient and the therapist as a model of how the patient experiences
and interacts with people in general. The fundamental concept is that
problems arise when things that your mind wants to do differ from what
your conscience thinks is the morally right thing to do. This "conflict" cre-
ates an inner crisis, so the unconscious tries to find a compromise, which
often results in problematic behavior that we can't seem to stop.
Deep exploration of these conflicts takes years of intense self-examina-

tion. For some, it can be an extremely rewarding way to understand one's
own character and to see the hidden conflicts that may cause certain
problems, such as low self-esteem despite making great achievements,
feeling trapped in a dissatisfying career, or difficulty having successful
relationships. There is a gradual change in people's underlying character,
as fears, insecurities, and conflicts are addressed, and, through a process
of working through issues, character changes in a lasting way. The follow-
ing is a very simple example of unconscious conflict that may be resolved
in therapy:
Christina is a 30-year old woman frustrated in her search for
the right man to marry. She wants a husband who is kind, honest, and
treats her well— not too much to ask for, she thinks. However, for some
unknown reason, whenever a man she dates turns out to be truly honest
and caring, she discovers something else about his personality that is so
annoying that she cannot tolerate him anymore, and she starts Looking
elsewhere for love.
In psychodynamic therapy, Christina discusses how she had been

"Daddy's little girl," with cheerful memories until she was seven, when
her father suddenly died. She was too young at the time to understand
what had actually happened. When Christine turned twelve, her mother
^
told her that her father had been hit by a drunk driver. When she heard [
the explanation, her reaction was anger at the driver who killed her father.
However, when she was seven, all she could think of was her intense
> sadness and confusion when the person she loved most in the world was
suddenly gone. In therapy she also recalled feeling tremendous rage at
her father for leaving her.
In the therapy, Christina began to see her own fear of getting mar-
ried because falling in love would put her at risk of being abandoned and
devastated again. The connection became clearer when she was talking
about her anger, and her thoughts associated to her last boyfriend and
her intense anger at him for occasionally coming home late from work.
In the therapy, as she felt more connected with the therapist and
opened herself up in sessions, she occasionally noted anxiety that her
. therapist would leave her or sudden feelings of intense annoyance at him
for things she had seen him do many times before without any emotional
^ reaction. Using this as an example, Christina was able to work through

\ her fears and rage with her therapist and develop a sense of trust and
stability in relationships. She noticed that she started feeling less angry
at her boyfriend of the time. The quality of her relationships improved, and
I at age thirty-four, she met a man she eventually married.
Psychodynamic psychotherapy is such a rich field that it is impossible to

discuss it in detail in this book. In addition, it is mentioned here as a type of
therapy for later in recovery because I discourage exploratory therapy during the
initial stages of sobriety, until addicts have stronger relapse prevention skills and
are able to handle the emotional stress that usually arises as you uncover deep
and unconscious feelings. However, later in recovery, when sobriety skills are
strong, psychodynamic psychotherapy can be extremely helpful to understand

and improve the self, as well as address deeper character issues that may be
the root of some addiction problems.
DEPRESSION:
When Nothing Feels Good-
Is This the Way Life Is Supposed to Feel?
CRYSTAL HAS AN amazing ability to elevate
mood. People who are depressed can feel

almost instant relief when they use it. One of the ways it works so quickly
is by releasing massive amounts of dopamine, one of the neurotransmitters
that improves mood and thinking. When the drug effects wear off, the brain
has much less dopamine than before, and the depression can become even
worse than it had been before using crystal.
Some people who have been medically diagnosed with major depression
take antidepressant medications. These medicines increase the availability
of such neurotransmitters as dopamine, serotonin, and norepinephrine
by preventing their removal (termed 'reuptake") from the spaces between
brain cells. While they do not increase production of these neurotransmit-
ters, they help the brain to maximize the usage of what is already in the
brain in order to maintain stable mood. Cr^^stal, on the other hand, releases
so much dopamine that it depletes the brain of its dopamine reserves. In
addition, it prevents brain cells from producing more dopamine, so it is
not able to replenish its depleted supply. With little dopamine left, there
—
DEPRESSION I 203
is nothing for antidepressant medications to work on, thus, they may lose
much of their effect or become entirely useless.
If you suffer from an underlying depression, a chronically low mood

puts you at high risk for relapsing because you are searching for anything to
make it feel better. If you have tried crystal, your brain already knows that
doing just a little can snap you out of a painful depression, even if only for
a brief time, and even if the price is worse emotional pain afterward. When
depression is severe, you may be desperate for any kind of relief, no matter
what the cost. To avoid the risk of relapsing, you need to know if you have
an underlying depression. If you do, you must treat it aggressively, both to
lead a better life and to reduce the risk of relapsing on crystal.
WHAT IS DEPRESSION?
"Depression" is such a commonly used word in the English language
that its exact meaning is unclear. In the medical field, we use the term
major depression to refer to a specific biological state of the brain.
Depression, in the broadest sense, means low mood. The stereotype

of a depressed person is someone who is always sad or crying. However,
"depressed mood" can be experienced in many different ways that are not
as easy to recognize. Some people experience depression as unhappiness
without actually feeling sad or tearful. Depressed people may also describe
their moods as hopeless, helpless, guilty, heavy, empty, bored, flat, joyless,
dark, irritable, unmotivated, low, distressed, or simply "bad." All humans

feel these emotions at certain times. When terrible events occur in life,
it is appropriate to feel unhappy. Depression, however, is different from

a bad mood, because the negative feelings are not appropriate; (1) they
may occur even when there is no identifiable cause; and (2) depressed
people become stuck in their low mood they feel depressed most of the —
time, and no matter how hard they try, they cannot shake the feeling, even
long after most people would have recovered from a sad event. Whatever
the cause, depressed people have an inabihty to feel happy or experience
pleasure, and they long to end the emotional pain and to feel normal again.
Depression can last several weeks to months, and sometimes it can last
for years.
In addition to low mood, major depression has several other symptoms

it is a physiological state of the brain and body. In addition to mood, some
physical symptoms include changes in sleep, appetite, and energy; poor

concentration; low motivation; mental fatigue, a decreased threshold for
bodily pain, and a decreased abihty to experience pleasure. Depression is
not simply a bad attitude or a weak character; it is a medical condition,
which may require medical treatment, such as medications, in addition
to therapy.
If you are depressed and do not address it properly, then recollections
of the euphoria of crystal can make the desire to use again irresistible,
seeming like the only way to find relief.
WHAT IS "MAJOR DEPRESSION"?

Physicians use a definition of depression using strictly defined crite-
ria. The broad range of symptoms reflects how multiple bodily functions
other than mood are involved, underscoring the biological nature of de-
pression. Technically biological depression iscalled major depressive
disorder. Table 14-1 lists the criteria for a major depressive episode
as it is defined in the DSM-IV:
TABLE 14-1
DSM-IV Criteria for Major Depressive Episode

MAJOR DEPRESSIVE EPISODE
A. Five (or more) of the following symptoms have been present during the same
2-week period and represent a change from previous functioning; at least one of
the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do note include symptoms that are clearly due to a general medical condi-
tion, or mood-incongruent delusions or hallucinations.
1. Depressed mood most of the day, nearly every day, as indicated by either sub-
jective report (e.g., feels sad or empty) or observation made by others (e.g.,
appears tearful). Note: In children and adolescents, can be irritable mood.

1
2. Markedly diminished interest or pleasure in all, or almost all, activities most of
the day, nearly every day (as indicated by either subjective account or observa-
tion made by others) '
>
,
|
[
3. Significant weight loss when not dieting or weight gain (e.g., a change of more
DEPRESSION I 203
than 5% of body weight in a nnonth). or decrease or increase in appetite nearly

every day. Note: In children, consider failure to nnake expected weight gams.
U. Insomnia (difficulty falling asleep or staying asleep) or hypersonnnia (sleeping

too much) nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others,

not merely subjective feelings of restlessness or being slowed down). [For |
example, pacing, rocking, hand-wringing]

|
6. Fatigue or loss of energy nearly every day.

|
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delu-

sional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness. nearly every day

(either by subjective account or as observed by others)
I
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation
without a specific plan, or a suicide attempt or a specific plan for committing
I suicide
B. The symptoms do not meet criteria for a Mixed Episode.
^ C. The symptoms cause clinically significant distress or impairment in social, occu-

j
pational, or other important areas of functioning.
D. The symptoms are not due to the direct physiological effects of a substance (e.g., a
I
j drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

I
I
E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a
loved one, the symptoms persist for longer than 2 months or are characterized by
marked functional impairment, morbid preoccupation with worthlessness, suicidal
ideation, psychotic symptoms, or psychomotor retardation.
Excerpted from the Diagnostic and Statistical anual of Mental Disorders. Fourth
Edition '
;
Dysthymia is a milder form of depression that is not as severe as ma-

jor depression. The degree of low mood may not be as severe, and there
may not be as may not be as many physical symptoms. However, the time
course of dysthymia is much longer, lasting for at least two years and often
much longer. Because dysthymia is not as dramatic and it is so longstand-
ing, it is often overlooked. After feeling mild unhappiness for such a long
time, people with dysthymia begin to believe that this emotional state
is how life is supposed to feel. Table 14-2 lists the DSM-IV criteria for
dysthymia.
TABLE 1A-2
DSM-IY Definition of Dysthymia

DYSTHYMIA
A. Depressed mood for most of the day. for more days than not. as indicated either by
subjective account or observation by others, for at least 2 years. Note: In children
and adolescents, mood can be irritable and duration must be at least 1 year.
B. When depressed, the patient has 2 or more of the following:
1. Poor appetite or overeating
2. Insomnia or sleeping too much
3. Low energy or fatigue
U. Low self-esteem
5. Poor concentration or difficulty making decisions
6. Feelings of hopelessness
C. During this 2-year period, the person has never been without the symptoms in
Criteria A and B for more than 2 months at a time.
D. No Major Depressive Episode has been present during the first 2 years of the
disturbance; i.e., the disturbance is not better accounted for by chronic fvlajor
Depressive Disorder, possibly in partial remission.
E. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode,
and criteria have never been met for Cyclothymic Disorder
F. The disturbance does not occur exclusively during the course of a chronic Psychotic
Disorder, such as Schizophrenia, or Delusional Disorder
G. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug
\ of abuse, a medication) or a general medical condition (e.g.. hypothyroidism).
H. The symptoms cause clinically significant distress or impairment m social, occu-

; pational, or other important areas of functioning.
Excerpted from the Diagnostic and Statistical Manual of Mental Disorders,

1 Fourth Edition
L, ^ „
DEPRESSION I 207
Both major depression and dysthymia can be extremely disabling.

People with these disorders feel miserable, and they have a diminished
ability to experience pleasure, even when everything in life is going well.
Major depression is fairly common, with a lifetime risk of 10 to 25 per-
cent among women and 5 to 12 percent among men. Dysthymia is less
frequently noted, with a reported lifetime prevalence of only 6 percent.

However, because the symptoms are more subtle and many people never
seek treatment, the actual prevalence is likely much higher.
|i
Depression of any type can increase your risk of relapsing on crystal
because the drug is a quick fix that can make that depression disap-
pear instantly. In the long run, however, it actually worsens depression.
If a person is biologically depressed when using, then the crash can be
even worse. If a person has had major depression in the past but is not
depressed when he or she uses crystal, the crash can trigger another major
depressive episode, and what starts out as just a crash can turn into an
intense, long-lasting depression. If you have a history of depression, using
meth is playing with fire — it may seem exciting, but it is dangerous and
can leave you burned. It is particularly risky for you, and you should avoid
it altogether.
The best way to treat depression is with psychotherapy and appropriate

medication when necessary. These are nonaddictive, long-lasting ways to
improve your mood. If you have any signs of depression, it is important to

see someone, whether it is your family doctor, a psychiatrist, or a therapist,
to have this formally evaluated. As long as you are depressed, you have a
[
greater chance of relapsing on crystal.
WORK:
When You Need
Keep Your to
Job Performance and Productivity High
YOU FIND that you

Do to accomplish all
it is difficult for
the responsibilities of
your job? Are you usually too tired to finish your work, or is the job is
so big that it exhausts you? This chicken-or-the-egg question is very

important because often, when people are not able to complete a job,
their bosses, and even they themselves, assume that it is their own
inadequacy However, it is important to consider whether the job itself is
really the problem. Almost all jobs have periods of increased or decreased
intensity —deadlines, due dates, seasonal fluctuations in businesses and
markets. However, if you find that your job always seems difficult to
keep up with, then this is a problem. If you need crystal or some other
stimulant to be able to perform your normal workload, is that really the
right job for you?
Many people have used meth to help themselves accomplish more
work: cramming for exams, writing last minute papers, or completing work
projects by their deadlines. But what starts as a one-time work aid for a
special project can become a constant requirement to be able to function
WORK I 209
at school or work. Some may quickly become addicted to the drug itself,
and their constant use keeps them working at an inhuman pace. For most,
however, it is a gradual process, in which, having seen what they were
able to do on meth, they begin to impose higher expectations on them-
selves.They accomplish more and more projects with meth, eventually
they become used to operating in high gear with little sleep and long work
hours. If crystal-fueled productivity becomes your new standard for work
performance, it can be an impossible standard to maintain without cr\'stal.
At first, this technique may seem to work Over time, the same amount
of meth becomes less effective, and you need to use more to accomplish
the same job. As you increase your use, you also start suffering more of
meths toxic effects, such as anxiety, distractibility, paranoia, irritability,
and disorganization, which, ironically, make your work suffer as well. But
by that point, your addiction is so strong that it is difficult or impossible
to stop using. The crystal that once made you a star at work may now lose
you your job.

If you are trying to recover from crystal addiction, keep your workload
reasonable. If this is not possible, the job is not safe for you, and you need
to consider another job. This is important advice for all people, regardless
of whether they are addicts. Moderation in everything you do, recreational
or work related, is important in maintaining a healthy balance of produc-
tivity and rest that will prevent you from burning out. "Work hard and
play hard" has become an American ideal — strive to be as productive as
possible, and reward yourself equally with pleasure. If you put out super-
human productivity, you expect superhuman compensation in return, and
a drug high can seem like the perfect reward. This Hfestyle is a setup for
relapse.
Take a moment to step out of your work, where the momentum of

the job can make you assume that the work expectations are reasonable.
Independent of your current job situation, what are you striving for in your
professional life? What do you really want out of your job? What does your
boss expect of you, and what do you expect of yourself? Set high standards
for yourself, but keep them realistic and healthy. If they are too high, you
set yourself up for disappointment. Some people scramble desperately to
avoid disappointment by any means, such as using crystal or other stimu-
lants to help them meet unrealistic goals. Before relapsing, take the time
to consider carefully what you really want out of life, and then decide
whether your job is able to help you achieve the life you want. You are
human, and you have Hmits — it is all right if you can't do everything in life.
Accepting your limitations is far better than trying to meet an unrealistic

expectation with drugs.
If you believe your work goals are realistic, is something else preventing
you from reaching those goals at work? Depression, social anxiety disorder,
attention-deficit/hyperacti\aty disorder, problems at home, the job itself,
or personality issues concerning a coworker or supervisor? If you identify

the real obstacle, then you can tackle it, instead of using a temporary solu-
tion like crystal, which can eventually turn from a solution into its own
problem.
A frequently underrecognized factor that can impair work performance
is attention-deficit/hyperactivity disorder (ADHD), and because of the
effect of stimulants on this disorder, many people with ADHD have acci-
dentally turned to meth for help. Read the next chapter if you suspect this
may be an obstacle for you in your daily life or at work.

IS
I
ATTENTION-DEFICIT/HYPERACTIVITY
DISORDER:
You're Not Lazy or Depressed,
So Why Do
You Still Have Trouble
Getting Things Done?
YOU ARE having difficulty focusing on

IF
your work but the work itself does not seem
like it should be a monumental task, attention-deficit/hyperactivity
disorder (ADHD) may be what is preventing you from focusing and
accomplishing things that should be easy for someone with your intel-
ligence. ADHD is a medical condition that causes difficulty in initiating
certain tasks, mentally focusing on uninteresting material, and filtering
out distracting stimulation, such as noise or activity around you. Some

people with ADHD experience restlessness and severe discomfort when
trying to sit still. There are several medications that dramatically improve
mental function. The most well-known medications for ADD and ADHD
are stimulants, such as methylphenidate (Ritalin) and amphetamines
(Adderall), which are similar to crystal, except that they have a much
milder effect.
Because crystal is a powerful stimulant, its effect on people with ADHD
can be so dramatic that the reason for its appeal is obvious. But the drug is
so powerful that it goes beyond treating the ADHD and causes addiction.
Beyond a certain point, it no longer improves concentration but worsens

mental function.
One must be extremely careful in making a diagnosis of ADHD. The
diagnosis has been overused to explain people's difficulty focusing. This
may be the result of several factors: (1) The name of the illness itself
misleading
— 'attention deficit disorder" implies that any person with prob-
is
lems with attention has this disorder. The reality is that many things can
impair attention, including anxiety, depression, bipolar disorder, schizo-
phrenia, dementia, brain injury, prescription and over-the-counter medi-
cations, drug and alcohol use or withdrawal, physical pain, and countless
medical illnesses; (2) In small doses, stimulants improve concentration in
almost all people, misleading people to believe that a positive experience

after taking a stimulant definitely means that they have ADHD; and (3)
American culture emphasizes the quick fix and the easy solution. The idea
that taking a pill could instantly improve one's mental function is extremely
appealing to many. Similarly, physicians pressured to see more patients in
less time may feel eager to find the simplest and quickest solution to help
their patients. The result of all of these factors has been the unintentional
overprescription of stimulants. However, when people with ADHD are
correctly diagnosed, the appropriate treatment can dramatically improve
their lives.
The DSM-IV divides attention-deficit/hyperactivity disorder into three sub-
groups: a predominantly inattentive type, a predominantly hyperactive-impulsive
type, and a combined type. The formal criteria are listed in table 16-1.
TABLE 16-1
DSM-IY Criteria for Attention-Deficit/

Hyperactivity Disorder
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER i
1
A. Either (1) or (2): j
j
1 .
Six (or more) of the following symptoms of inattention have persisted for at least
I
6 months to a degree that is maladaptive and inconsistent v\/ith developmental
j
level [i.e., that is more than would be expected compared to a child's same-age
1
peers]:
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER I 213
Inattention
a. often fails to give close attention to details or makes careless nnistakes
in schoolwork, work, or other activities
b. often has difficulty sustaining attention in tasks or play activities |
c. often does not seem to listen when spoken to directly 1
d. often does not follow through on instructions and fails to finish school- {
work, chores, or duties in the workplace (not due to oppositional behav- I
ior or failure to understand instructions) i
e. often has difficulty organizing tasks and activities

f. often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort (such as schoolwork or homework) ;
g. often loses things necessary for tasks or activities (e.g., toys, school
assignments, pencils, books, or tools)
h. is often easily distracted by extraneous stimuli
i. is often forgetful in daily activities
2. Six (or more) of the following symptoms of hyperactivity-impulsivity have per-

sisted for at least 6 months to a degree that is maladaptive and inconsistent
with developmental level [i.e., that is more than would be expected compared
to a child's same-age peers]:
Hyperactivity
a. Often fidgets with hands or feet or squirms in seat
b. Often leaves seat in classroom or in other situations in which remaining
seated is expected
c. Often runs about or climbs excessively in situations in which it is inap-
propriate (in adolescents or adults, may be limited to subjective feelings
of restlessness)
d. Often has difficulty playing or engaging in leisure activities quietly
e. Is often "on the go" or often acts as if "driven by a motor"
f. Often talks excessively
Impulsivity
a. Often blurts out answers before questions have been completed
b. Often has difficulty awaiting turn
c. Often interrupts or intrudes on others (e.g., butts into conversations or
games)
d. Some hyperactive-impulsive or inattentive symptoms that cause impair-
ment were present before age 7 years.
e. Some impairment from the symptoms is present in two or more settings
(e.g.. at school [or work] and at home).
f. There must be clear evidence of clinically significant impairment in
social, academic, or occupational functioning.

g. The symptoms do not occur exclusively during the course of a pervasive
developmental disorder, schizophrenia, or other psychotic disorder and
are not better accounted for by another mental disorder (e.g.. mood dis-
order, anxiety disorder, dissociative disorder, or a personality disorder)
Excerpted from the Diagnostic and Statistical Manual of Mental Disorders, >
^
Fourth Edition
If you think that you might have ADHD, here are some important
points to consider:
ADHD is a lifelong biological condition. Unlike other possible reasons
for impaired attention, ADHD is notable from early childhood,

and it is likely active even at birth. The DSM criteria states that
symptoms must be present before age seven because this is

when most children start school and are put into a structured
environment, so this is one of the first times that children are
forced to focus for any sustained period of time. If attention
problems started later in life, ADHD is not the reason you have
difficulty concentrating. If attention problems are episodic and
vary with your mood or events that occur in your life, then it is
extremely unlikely that you have ADHD.

A positive response to stimulants does not necessarily mean that you have
ADHD. Many people have tried a friends ADHD medication,
such as Ritalin, Adderall, or Metadate, and they found that they
were able to focus better. But this response alone does not mean
that they have ADHD. Almost everyone focuses better to some
degree with stimulants, though as you increase the dose of the
stimulant, anxiety and excitement also increase with use, and
concentration may actually become more difficult. Conversely,
most people with ADHD actually find that stimulants slow down
their thinking and give them a feeling of quiet and calm.
If you suspect that you have ADHD, you should see a psychiatrist or
psychologist and have a formal evaluation. If indeed you have ADHD, then
you should seek appropriate treatment. Fortunately, there are now many
nonaddictive, nonstimulant treatments for ADHD, which can improve
your quality of life, enhance your mental functioning, and decrease your
risk of relapsing onto crystal. In addition, there are many nonmedication
behavioral strategies that can help you to keep organized and optimize
your focus. If you have an addiction to crystal, then using stimulants to
treat ADHD is not a good option for you because it mimics the activity of
meth too closely and puts you at serious risk for relapse.
n
LIFE IS A BALANCING ACT:
Stress Management
A CARDINAL RULE
crystal addiction, other
in relapse prevention, for
chemical depen-
dencies, and as a general rule for life, is to minimize or manage stress.
Anxiety and stress are natural feelings in life. Mother Nature gave our
bodies the ability to feel stress to motivate us to do things, whether we
are running from a predator for survival or working in hard in school to
get good grades. Cortisol, one of the hormones involved in stress, illus-
trates how stress functions in our lives. The adrenal glands secrete the
hormone Cortisol in response to physical or emotional stress. A person
with inadequate Cortisol function, also called adrenal deficiency, gener-
ally suffers from fatigue, dizziness, and weight loss, among several other
symptoms. However, in the setting of a severe stress, such as a bacterial
infection, the inability of the body to mount a normal stress response by
increasing Cortisol production can lead to dangerously low blood pres-
sure, shock, and possibly death. Clearly, stress has its place in life.
However, all good things must be kept in moderation, or they cause prob-
lems. Feeling overloaded from stress can also be extremely problematic. With
—
regard to crystal addiction, too much stress that is not managed properly can
lead to a crystal relapse. In addition to giving you energy that can help you do
more work, meth can offer an escape from the drudgery of your job to a state
of artificial happiness, it can distract you away from unpleasant feelings, it can
boost a low mood caused by chronic frustration, overwork, and fatigue, or it
can feel like a well-deserved reward for your hard labor. When you are vulner-
able from too much stress, there are so many attractive fruits hanging from the
forbidden tree of Eden that it can be extremely difficult to resist the temptation
to pick one for a bite of sweet, delicious relief.
Medical studies looking at the physiological responses to stress, anxi-

ety, and depression have consistently shown that high levels of stress or
depression adversely affects almost every organ system. Some examples

of the broad range of negative effects include: exacerbation of high blood
pressure, worsening heart health, decreased survival rates in depressed
people who have had previous heart attacks, slower wound healing, and
impaired function of immune cells, which are needed to fight infection
this last example is of particular importance to people with HIV, who need
to optimize their immune function, which is already compromised by the
virus. Brain imaging studies give visual proof of the physically toxic effects
of anxiety and depression, showing destruction of brain cells in certain
areas, compared to people who were treated for these conditions. Most of
us can recall some experience in which stress affected our bodies: intense
physical or mental stress may have caused some women to miss their men-
strual period; both men and women may have more outbreaks of herpes
or acne during particularly difficult times. Excessive stress is dangerous in
many ways because of the increased the risk of relapsing onto crystal and
its myriad negative impacts throughout the human body.
There are two different ways to approach managing stress: ( 1 ) prevent-
ing it from overaccumulating, and (2) finding ways to counter it when it
is unavoidable —an example would be having an effective outlet to relieve

stress, such as regular exercise. A good stress management plan should
address stress from both directions.
PREVENTING STRESS FROM ACCUMULATING TOO MUCH

If you are feeling stressed, it is important to look find the source. Is it
your job? Your relationship? Family conflict? Whatever the cause, you need
LIFE IS A BALANCING ACT I 21?
to identify it. Sometimes the source is obvious, but sometimes it is not

so clear. For example, someone may be stressed because of working long
hours at an overly demanding job. Others may be working long hours at
work, but they stay at the office late because the real stress is something
outside the office, such as family conflict, low self-esteem and loneliness
outside of the workplace, problems coming to terms with one s sexual ori-
entation, and so on. In those cases, working long hours may be an attempt
to escape the real source of anxiety, which may be conscious or outside of
the person's awareness. The less obvious cases may require some in-depth
detective work, and a therapist may be a valuable resource in helping your
investigation.
Identifying the source of the stress is an important first step. Only

then can you address it. What is the cause of the stressful situation? For
example, do you routinely work late hours because you will lose your job
if you do not maintain an unrealistic workload? Or do you linger at the
office because you are reluctant to go home, where you dread the angry
arguments you regularly have with your spouse?
how can you effectively address
After pinpointing the cause of stress,
it? Ifhome is usually a battleground where you usually argue with your
partner, how can you communicate more effectively? Have you considered
couples' counseling? If there a conflict with a coworker, can you ask a

supervisor to intervene and mediate the problem so that your daily inter-
actions are less unpleasant? If your job is too demanding, can you discuss
this with your boss and try to work out a more realistic plan for how to
accomplish the work —perhaps setting a more practical time frame, hir-
ing an assistant or additional employees to work on a project with you, or
restructuring the project.? If you have been silent about your frustration
at this job but nothing has improved, and talking with your boss is not
helpful, should you consider working somewhere else?
Just the initial act of creating a plan of action to deal with a problem
can be therapeutic because it gives a framework to your stress, which may
have been somewhat vague and unclear; it keeps your attention focused
on reaching a better state, and making a list of strategies to address the
problem may give you some sense of taking control. If you hide from
the problem, for example by mentally escaping through drugs or physi-
cally avoiding the stressful place, the problem will continue, and growing
feelings of powerlessness and hopelessness simply compound the stress.
Regaining control by addressing the problem is an important part of lower-

ing stress.
If you already know what things in general make you unhappy you are in
a great position to prevent future stress by avoiding those situations. If you

know that you do not work well in a large corporate environment, or that you
cannot tolerate jobs that normally require ten- to twelve-hour workdays, then
you should avoid those types of jobs. If you know that interactions with certain
people or family members make you feel anxious, annoyed, or angry even after
countless sincere efforts to address the conflict, then figure out different ways
to interact with them that will limit your contact to whatever is necessary, but
no more. Clearly understanding your own likes, dislikes, and voilnerabilities will
not only help you get out of stressful situations, but it can also help you avoid
getting into them in the first place.
FINDING AN OUTLET FOR YOUR STRESS
Certain things in life are unpleasant but unavoidable. In those cases,
it is important to have effective ways of coping with your negative feel-

ings. If you think of stress as pent-up energy that accumulates inside you,
it is intuitive that periodically some of the energy needs to be released to
reduce the pressure we feel inside and allow us to feel calm. Consider the
anxious discomfort of an extremely full bladder and the feeling of relief
and calm after urinating and releasing the built-up pressure. Some people
find that exercise is helpful, such as running, biking, weight training, or
other sports. Exercise literally expends energy that has built up inside, and
makes you tired, which can also help you to rest and sleep better. It also
increases your body's levels of dopamine, norepinephrine, and serotonin,

as well as releasing endorphins, your body's own natural opiates. These
effects explain why exercise has some antidepressant and antianxiety
effects similar to many psychiatric medications. These findings as well as
multiple other studies show that exercise improves mood.
Some people find that physical activities that explicitly release aggres-
sion, such as boxing or martial arts, help them decrease tension. In addi-
tion to the benefits of exercise discussed above, these particular sports also
allow you to redirect feelings of frustration and anger in a safe way. For
example, hitting a punching bag can symbolically represent your boss who,
while angry about something unrelated to you, yelled at you last week.
LIFE IS A BALANCING ACT I 219
Complaining about it right then might have cost you your job, but if you
never address your feelings, you will carry around the anger, which will
add to other stresses that accumulate over time. Fighting sports can help
you redirect your unexpressed frustrations in a meaningful but safe way.
They can help you feel more in control because in addition to expending
energy, practicing a "fighting art" can counter the feelings of powerlessness
from your situation.
Be cautions. If hitting a punching bag while imagining your boss's face
on it does not bring you relief but makes you ruminate on your problems
even longer, then this is not a helpful activity In this case, aggressive fight-
ing sports only perpetuate your anger and prevent you from letting go of
your negative feelings. In that case, find a different activity to relieve stress
before you build up so much anger that you find yourself in trouble.
RELAXATION
In addition to expending pent-up energy, another strategy to reduce

stress is relaxation. If you think of exercise as a way of "pushing out"
negative energy, think of relaxation as a gentle way of "releasing" those
feelings, letting them go. Letting go is another fundamental concept in
relapse prevention and twelve-step philosophy. For successful recovery
from addiction, you need to let go of trying to have total control by admit-
ting that you have an addiction problem that you cannot manage alone;
let go of crystal from your life, and let go of tension and stress before they
overwhelm you.
People have developed countless ways to relax, from chanting ancient
Buddhist mantras to taking a nice, hot bath —with so many possibilities,
you need to find an activity that fits you well. For example, some people
find meditating by chanting in a group to be extremely soothing and relax-
ing. Some may feel it is not their style and makes them feel awkward and
uncomfortable — rather than help you feel better, it could increase your
stress. Some suggestions for easy strategies to clear your head when you
need to calm down include strolling through the neighborhood, taking a
leisurely drive (not speeding), sitting on a park bench watching the squir-
rels play, relaxing in front of your favorite TV show, or watching a movie

at the local theater. Here are some tips for getting the most out of these
and other similar activities:
1 . Do the activity a leisurely pace, and give yourself enougt) time to do it. If you
only give yourself 30 minutes to take a break and go to the park,
but it takes 10 minutes to get there and 10 minutes to get back,
then the whole experience becomes a hurried task — ^just another
burdensome task on your list of things to do. Either give yourself
more time or pick a place to relax that is closer.
2. Keep your focus on the relaxation activity. If you are walking or driving,
look at the road, at the scenery around you. Be more aware of your
surroundings and enjoy the break from your day —take in the view.
Do not just go through the motions of walking or driving while

your mind continues to churn as you worry about the stressful
deadline you have to meet or replay in your head the angry fight
that you just had with your spouse. By focusing on your immedi-
ate surroundings, you redirect your attention to the present, and
away from your anxieties that lie in the past or the future. Take a
mental vacation, and use the time to clear your head and let go of
your unpleasant feelings.
3 . Do not place any expectations on yourself while doing your relaxation activi-
ties. While you are walking, you don't need to reach a certain goal
in a certain amount of time. As you look at the scenery around you,
you don't have to feel the joy of resplendent nature — if you expect
your walk in the park will be like Walt Disney's Bambi, you'll likely
feel disappointed and annoyed that you wasted your time. While
the ultimate goal is to make you feel better, the activity itself
doesn't really matter. Promise yourself not to set any expectations,

and do not worry about feeling better during the relaxation activ-
ity itself. It is all right not to feel anything. If you set up another
expectation, your effort to relax becomes just another test to see
if you will pass orfail. The mere fact that you are engaging in the
activity means you have already met your goal, so feel satisfied
with that and focus on the activity.
4. Empty your mind of anything outside your activity and let the other things
go. Focus on each step of what you are doing, where your body is,
what is around you. Observe your surroundings and just take them
in. Diverse schools of thought from widely different philosophies
all seem to converge on this point. Western psychology describes
it as refocusing your attention away from stress. Zen Buddhism
teaches the concept of mushin (no mind). Yoga masters emphasize

the importance of centering your mind on the present, to bring
unity to the mind, body and spirit —not allowing you to distract
yourself with worries about the past and the future. -
In addition to the quick fixes listed above, the following are some ex-
amples of activities, each with different highly evolved philosophies, all
specifically meant to help you to relax. These are only cursory descrip-
tions, but if any of them pique your interest, I encourage you to find out
more and give them a try. You may be surprised that you like something
completely new. If not, move on to something else. You should have at
least one or two activities that you can turn to for relaxation. Whatever
activities you choose, make sure they feel right for you.
Yoga
Yoga is an ancient spiritual discipline originally developed in the Indian

subcontinent five thousand years ago. The basic text of Yoga philosophy,
the Yoga Sutras ofPatanjali were written in the second century B.C., though
this formalized Yoga philosophy was a systemization of a number of older
spiritual traditions that had existed thousands of years earlier. Yoga strives
to attain a higher state of consciousness and freedom from the cycle igno-
rance, worldly suffering, and rebirth. Modern yoga has evolved into several
branches, each emphasizing different methods of achieving the common

goal of enlightenment. For example. Hatha yoga uses a combination of
gentle postures and breathing techniques to purify the mind, body, and
spirit, while Pranayama breathing exercises try to clear the channels in the
body that carry the universal life force, called frana.
Yoga meditation styles are so varied that it is impossible to generalize

the experience. For example, certain schools emphasize gentle techniques,
focusing on breathing and balance; others can be extremely intense and
physically challenging, with intricate, difficult poses; Bikram yoga is a
series of intricate poses practiced in extreme heat, which induces euphoria
and profound inner calm in some but which is intolerable to others.
From a medical and psychiatric perspective, many aspects of yoga make
sense in a Western, scientific sense. The various breathing techniques and
body positions change blood flow to the brain and to the other parts of the
body in ways that are unusual in ordinary sedentary life. The breathing
techniques help with relaxation because of the amount of oxygen and car-
bon dioxide that your body accumulates or breathes off. Certain breathing
techniques stimulate the vagus nerve, which runs through the chest and
lower neck. Through various neural connections, the vagus nerve connects
to several parts of the brain, including certain fibers in the thalamus that
decrease activity in the frontal cortex and lower anxiety; the hypothalamus,
improving alertness and attention, and producing feelings of satisfaction
and pleasure; and the limbic system and forebrain-reward systems, induc-
ing feelings of pleasure and bonding.
The effects of vagus nerve stimulation have been well documented in
medical literature, and a device called a vagus nerve stimulator (VNS)

was developed to treat depression that did not respond to conventional
medications. The VNS is implanted in a procedure similar to implanting

cardiac pacemakers, with electrodes stimulating the vagus nerve rather
than the heart..
Siidarshan Kriya Yoga (SKY) emphasizes four breathing techniques that
stimulate the vagus nerve.SKY has been studied in severely depressed people
and has been found to be extremely effective at treating depressed mood. SKY
and a simplified version called Breath Water Sound (BWS) were taught to
survivors of the 2004 tsunami in Southeast Asia and the victims of Hurricane
Katrina in 2005, and these interventions were found to be powerfully effective
in reducing symptoms of posttraumatic stress disorder.
The way that yoga is practiced, focusing your mind on your own body,
concentrating on your physical being (some positions are very difficult and
require intense effort), and carefully manipulating your breathing patterns,
you become entirely focused on the here-and-now. This is completely
opposite to the way people normally operate when they are anxious, either
ruminating about problems from the past or worrying about the future.
Rarely do people let go of these thoughts and simply look at themselves
just at the present moment in time. Previously, I discussed the concept
of letting go and strategies of relaxation aimed at relieving you of past and
future worries. Yoga is one of many ways to achieve this state of mind.
Whether you believe in the spiritual aspects of yoga, are intrigued by its
physiological effects on the brain, or are just generally curious about the
practice, I encourage you to try it. Many people practice yoga, and even
without understanding the "real" way that it causes change in them, they
LIFE IS A BALANCING ACT \ 223
leave feeling strangely peaceful and Some report feeling euphoric.

relaxed.
In a study of patients with severe depression who required hospitalization,

those who were randomly assigned to receive an intensive twenty-two-hour
training in SKY were found to improve as well as the others, who were
randomly assigned to receive conventional antidepressant medication.
Since the biological effects of yoga are real, it should not be taken lightly.
Women who are pregnant and people who have medical conditions, such
as uncontrolled high blood pressure, seizure disorder, significant heart dis-
ease, recent injuries or surgery, or any other serious medical illness, should
consult his or her physician before considering a yoga program. Bipolar
disorder and psychotic disorders such as schizophrenia may be worsened
by SKY breathing techniques.
If you decide to try yoga, be aware that at this time there are no stan-
dard certification or licensure requirements to be a yoga instructor, though
many instructors attend yoga institutes, where they are certified after
completing a training program. Certification by the larger yoga centers

usually requires at least 200 hours of teaching experience, daily practice
of yoga for six months, total abstinence from alcohol and other drugs,
and adherence to a strict vegetarian diet; obtaining certification from
these training programs therefore demonstrates a high degree of personal
dedication and experience in yoga. Nonetheless, keep in mind that there
is no regulation of the quality of education at yoga schools. Until clearer
standards are set, make sure that your yoga instructor is at least certified
by a yoga school, and obsewe a class before deciding if you are comfort-
able participating in it.
Massage
Massage sounds like an indulgence rather than a health-maintenance

activity. The Protestant work ethic that is considered the basis of American
culture trains us to believe that truly good things can be achieved only
through hard work, not pleasure. We still feel the influence of this old
work ethic today, a good example being the expression "no pain, no gain,"
which became popular in the 1980s. However, there are some enjoyable
and indulgent activities that can also be good for you, such as massage.
There are various schools of massage. Examples include Swedish mas-
sage, deep tissue massage, sports/medical massage, qi gong, shiatsu, and
Thai massage, among many others. own theory as to why

Each has its
it is effective. However, they all have something in common: in some

way they physically "force" your muscles into a state of relaxation. While
meditation tries to achieve a relaxed state from within (the mind), mas-
sage complements this by physically ''forcing" a relaxed state from without
(the body).
It can be astounding how much stress, tension, or emotion we hold in
our muscles. People with stress commonly suffer from stiff necks, back-
aches, or tension headaches. first became truly aware of how much ten-
I
sion and emotion our muscles hold after the terrorist attacks on September
11, 2001. The American Red Cross set up a vast disaster relief service
center in New York for all people affected by the disaster. Volunteer ser-
vices ranged widely, including medical and psychiatric evaluations, legal
assistance, and provision of various social services. Among the many dis-
ciplines was a large group of volunteer massage therapists. Many people

tried massage, seeking comfort and stress relief. Others timidly requested
massages, thinking that they would take advantage of a good opportunity
for a free massage, while they had come to the Red Cross Center to find
help for someone else. The response of all people, regardless of why they
came, was dramatic. Some of those who had come for others' sake and
who had thought they were strong and unaffected by the attacks found
themselves in tears in the middle of a massage session. They had been
holding in so much stress that the massage literally kneaded out the pent-
up feelings. When I witnessed this, I realized how powerful a tool massage
could really be.
Unlike yoga, massage therapy is regulated by each state government,
requiring specific training and licensure. However, there are so many styles
of massage, and the experience of touch is so unique, that you can have
a completely different experience from two licensed massage therapists
practicing for the same length of time. Make sure your massage therapist
is licensed. Ask what kinds of massage techniques he or she uses and how
long he or she has been practicing. If the response to these questions is
vague, find another therapist —anyone who is truly trained and licensed
would be able to answer these questions in detail. Consider what kind of
massage would be more relaxing —the more superficial Swedish massage
(which can still be vigorous depending on the massage therapist) or the
much harder and sometimes painful deep-tissue massage. Pick a therapist
with a gender you are most comfortable with — this is a nonsexual experi-
ence, and your comfort with the therapist is essential for the massage to
reduce your stress. And make assumptions about gender and the
don't
strength of the massage — some women give powerfully deep massages,

and some men have a more superficial style. Specify what you are looking
for when you speak with a potential massage therapist. And most impor-
tant, if you have had any kind of injury, recent surgery, or illness check with
your physician to see if massage is safe for you
Acupuncture
Acupuncture is an East Asian medical treatment based on a perspective

of the body that is completely different from that of Western medicine.
While there are many schools of acupuncture, they all share a fundamen-
tal belief that the body is made up of a series of meridians, or channels
for energy called qi (pronounced "chee '). In addition, they believe that
the body is governed by two opposing universal forces: yin and yang.
They complement each other, and when one is deficient or in excess, the
body is not balanced, resulting in poor function. According to the teach-
ings of traditional Eastern medicine, illnesses, including pain, stress, and
addiction, stem from blockages of qi and imbalances of yin and yang.
Hair-thin needles are inserted at points along these meridians to open up
blockages and improve energy flow. In modern acupuncture, sometimes
small amounts of electricity are even used to stimulate the energy chan-
nels though the needles. Correcting the flow of energy in your body using
acupuncture and balancing yin and yang through diet and other lifestyle
changes, along with other eastern remedies, can help restore you to health.
Many people report leaving an acupuncture session feeling relaxed and
tranquil, with a general sense of well-being.
Western medicine has tried to make sense of acupuncture, explaining it
with the principles of Western medicine, such as finding nerve pathways

that may be directly stimulated by the needles. However, these studies
have not been able to explain adequately all the things that acupuncture
is capable of doing. In some extraordinary cases, acupuncture has been
used as an anesthetic in surgery, without the use of any pain medications.
However, acupuncture is considered to be most useful in improving milder
ailments by achieving balance in the body and leaving the patient with a
sense of overall well-being. Acupuncture has been found to be particu-

larly helpful with certain pain syndromes, addiction, anxiety, high blood
pressure, digestive problems, and even hemorrhoids. However, for major
medical illnesses, I strongly advise patients to use Western medicine,
consider acupuncture as an adjuvant treatment. Even in East Asia, where
acupuncture was developed, most doctors and common people believe
that it is best used in conjunction with Western medicine, with each
complementing the other.
Some people respond very dramatically to acupuncture, while others

may not have much response at all. Some studies completely debunk any
therapeutic value to acupuncture, though this goes against the positive
experiences of millions of people. Some studies that find validity in the
treatment have also found that if acupuncture has not shown any benefit
after three to four treatments, the statistical chance of any improvemicnt
with continued acupuncture is extremely small. In that case, it is time to
try a different relaxation strategy.
Acupuncture is also a practice that is regulated by state governments,

requiring licenses to practice. If you try acupuncture, make sure that the
practitioner is licensed in your state and always uses brand-new needles
that are individually, sterilely wrapped. In general, acupuncture by itself is
extremely safe and surprisingly painless and soothing. If the acupuncturist

recommends herbal remedies in addition to the acupuncture, be cautious ;
and discuss this with your physician first, as they can be just as powerful as
pharmaceutical medicines and drugs (remember that cocaine, marijuana, i
heroin, and opium are all from plants) and may chemically trigger a relapse
^
or interact with medications that you are already taking.
Reiki
Reiki is both an ancient and a new form of holistic healing with roots
dating back several thousands of years in Tibet. It is a system of healing
that involves the placement of hands directly on the recipient, as well as
holding one's hands near the recipient's body without any actual physical
contact. The "laying on of hands" as a treatment for ailments has existed
throughout history in various cultures, even in Christian fundamentalist

groups in the United States, so it is difficult to know the true origin of
Reiki. A Japanese educator named Dr. Mikao Usui developed the modern
LIFE IS A BALANCING ACT I 22?
practice of Reiki in the late 1 800s, looking for a spiritual system of healing
through study, research, and meditation. He reported that at one point, he
experienced a metaphysical transformation, and based on that experience
he developed a system of healing using what he called the "Universal Life
Force," which is channeled into a recipient's body. Ailments are concep-
tualized as an obstruction of the flow of the Universal Life Force, and
the Reiki practitioner acts as a conduit to direct the energy back into the
recipient.
By tradition, the Reiki healing system was passed down from master to
disciple in Japan. However, all of the original masters in Japan died, except
for one master, who immigrated to Hawaii, where she continued to teach
Reiki to Americans. For this reason, Reiki is now more developed and
widely practiced as a healing art in the United States than it is in Japan.
Anecdotally, many people have reported unusual experiences with Reiki,

including stimulation of bowel activity, heavy salivation, muscle twitches,
or unusual body sensations, even when there is no physical contact with
the Reiki healer. Some people simply leave a session feeHng a deeper sense
of calm. Some people do not notice any effect at all.
While extreme Reiki enthusiasts believe that Reiki can heal almost
any physical ailment, many people, including some Reiki practitioners,
feel that its greatest use is for relaxation, which in turn improves overall
health. 1 do not recommend that people use Reiki as a primary treatment
for any medical condition. However, effective relaxation techniques are

good complementary treatments for almost all medical conditions because
stress has such a pervasive negative impact on the entire body. While mas-
sage may be wonderful for some people, may be inappropriate for people
it
with certain physical injuries or people who feel more anxious from too
much physical contact. In this regard. Reiki may be a nice alternative, with
minimal to no physical contact.
^„
Meditation
'*
Meditation is defined by Merriam Webster's Dictionary as focusing the

^
mind or pondering in self-reflection. There are many practices that would
f
fall under this definition, such as prayer. Transcendental Meditation,
Buddhist chanting, Zen meditation, and even sitting in a comfortable chair
at home focusing on colorful fish in an aquarium.
Because meditation can be done in so many ways, the best kind is what-
ever method fits your personaHty, Hfestyle, and personal philosophy. Your
goal is to feel more tranquil, so finding a good fit, like the right size shoes,
will make the difference between a comfortable, relaxing experience, in

which you can clear your mind, and an uncomfortable and self-conscious
activity in which your mind is preoccupied with your discomfort. Do what-
ever feels good to you.
EXERCISE 17-1 MEDITATION ROUTINE 1
THIS meditation exercise combines aspects of many different medita- \

'
tion and relaxation techniques. Try to do this exercise twice a day— once
in the morning to start the day in a tranquil state of mind, and once in -
the evening to help yourself unwind from the stresses of the day. Allow
'
yourself 5 to 1 0 minutes each time you do this. If you cannot spare 5 to 1 0
minutes to devote to your own well-being twice a day, you've identified a i
significant problem right there!
Find a comfortable, dark, and quiet place to sit or lie down and close your
^
eyes. The first time you do this, you may want someone else with a calming ^
voice to read you these instructions and guide you through the steps.
1 . Sit or lie comfortably with your eyes closed. If you are lying down, i
lay your arms and hands at your sides. If you are sitting, place the
palms of your hands on the tops of your thighs. 4

2. Take note of your body, its position in the chair or on the bed, how
it feels lying against the cushions. If you are sitting, feel the sen- \
sation of the palms of your hands resting on your thighs.

3. Shift your attention to your neck and your shoulders and note
how they feel. Imagine they are made of lead, and let them drop.
Notice how you may have been tensing them and holding them up,
and try to appreciate their heaviness as you let them fully relax.
^. Take in a slow deep breath through your mouth over 5 seconds,
i then exhale slowly through your nose over 5 seconds.

5. Take in another slow deep breath and visualize the air coming in
through your mouth and filling your lungs. Imagine it as white

steam or vapor, filling every pocket and opening in your lungs, and
be aware of your lungs gradually expanding and filling with air.
6. Slowly exhale through your nose and visualize the air coming out
in streams of slightly grayish vapor from your nostrils, carrying
out any bad feelings, stress, tension, and "impurities"— the gray-
ish tinge— that you have stored inside you.

7. Repeat this deep breathing and visualization a total of 5 times.
8. After completing 5 cycles of deep breathing, repeat the following words

out loud, thinking deeply about their meanings as you say them:
Just for today,
I do not need to get angry.
I do not need to worry.
I will be grateful for what I have.
I will work hard.
I will be kind to others.
9. After saying these statements, repeat the deep breathing again for
5 more breaths
10. Slowly count backward from 10 to 1, and when you reach 1, slowly
open your eyes. Now you are done.

II
:
WHO IS IN YOUR SOCIAL CIRCLE?

Dealing with Loneliness
and Finding a Sober Group of Friends
YOU ARE trying to stop crystal but most

IF
of your friends still use it, as well as other
drugs, you have an extra challenge in trying to stay sober. Remember the
mantra 'people, places, and things" reminding you that the people you
associate with crystal are dangerous because they can easily pull you
back into using again. People who used crystal in private —hidden from
family and friends, doingmeth only with strangers, sex hookups, and
their dealer —
may still know several sober people who are not triggers
and who can support them through their efforts to stay clean.
But what if your main social circle is a group of other drug users, people
with whom you used to spend most of your free time, whether it was just
hanging out at home getting high or going out together to parties where
everyone was using drugs. What if you are a gay man, and your social
circle is all circuit boys who talk mostly about clubs, the best DJs, and
what drugs they plan to do for the weekend? If any of these resembles
your situation, then trying to separate yourself from these people can be
difficult because it means giving up your entire social network, the people
WHO IS IN YOUR SOCIAL CIRCLE? I 231
you are accustomed to calling whenever you are bored, lonely, or looking
for something to do. If you have to cut ties with these people, then how
are you going to make it through each day?
Whoever you are, and however you identify yourself it is essential to under- ,
stand the personal significance of your own social group. Who are the people in
your social circle of drug users and why are they so important? Whether gay or
straight, ask yourself this question and consider whether other people can meet
these same needs. If you are a straight young man in a small rural town and just
out of high school, you may have a core group of friends you know from school.
You've been friends since freshman year, which feels like a lifetime, and in your
small town there don t seem to be many people to choose for friends. But are
there really no other people, or is it just easier to keep hanging with the same
crew you always did? Unless you and your friends were the only people in your
graduating class, there are probably other people that are potential friends. The
easiest way to meet sober friends is to go to the nearest twelve-step meeting.
Even if you aren't exactly the same age, you may find that you have more impor-
tant things in common than your age, especially your wish to stay clean!
Ifyou are a gay man in the club/circuit scene, believe it or not, there
are other fun, attractive, and gay-affirming people in the world who do
not use drugs, and they can offer you the same support you had from your
party friends. In fact, they can probably offer you even better support
because they may be more interested in the person you are, unlike many
club friends whose main concern is whether you are have any E and K to
share or if you're going to give Tina a call this weekend.
Gay men who were introduced to the party scene when they were just
coming out may have an even greater challenge separating from their social
group. Before coming out, they may have been completely closeted and
unable to be their true selves with anyone. Alternatively, their peers may
have known they were gay and ostracized them, making them feel they
were worthless outcasts. The group of partying friends may be the first
people ever to fully accept them, the first to make them feel liked and to
welcome them into their group. More than just people with whom they
are accustomed to passing time and doing drugs, these friends have strong,
positive emotional meaning in these men's lives.
Similarly, circuit parties, which are huge gatherings wath thousands of gay
men, most of them high on club drugs, are places where many gay men first felt
they could openly and wholeheartedly celebrate their sexuality, feeling happy,
attractive, and accepted into a community. The feeling of being sun-ounded

by a sea of gay men contrasts so sharply to the feeling of isolation from their
closeted pasts. Therefore, the entire scene — the friends, the parties, and the
drugs —has a monumental emotional significance to these men.
Asking these gay men to stop seeing their party friends and to stop going
to circuit parties is asking them to turn their backs on the first people
who made them feel accepted and not to go back to the place where they
remember first truly feeling part of a community While all these fond
memories have some validity, in reality, drugs were likely the real glue that
held much of this group together, and ultimately, the drugs and sex became
the main draws to the circuit parties. The positive associations to these
people and places are so deep that it can be incredibly difficult to let go.
As positive as their feelings may be, however, this group of friends who
once seemed like a lifeline gradually turned into a ball and chain dragging
them to a drowning death by crystal addiction.
If these gay ex-party boys have no significant friends outside the club
and circuit scene, then completely separating themselves from this social
scene will bring on a period of profound loneliness and isolation. They

will need a strong support system (including their drug counselor, thera-
pist, twelve-step groups, other recovery groups, and any sober family and
friends who are willing to help) to maintain their motivation to stay clean
while they explore ways of meeting new, sober gay friends who share a
bond with them other than drugs. If they make it through this period, they
will discover what it is like to have gay friends who truly like them for who
they are, not just because they do drugs together at parties.
If you are an offbeat club kid, marginalized at school as "that strange
chick," but considered "the cool, cute babe '
in the rave scene, you may be
surprised to find other teens like you who swim outside the mainstream
but still think they are cool, and are clean and sober. When you hear the
obnoxious Barbies at school make fun of your different clothes, if you stop
going to raves, where the scene and the drugs remind you that you are
still that cute, cool, babe —now you are forced to look at how you really
feel about yourself and admit how much of an effect those vicious girls
at school really had on your self-image. You felt cool at the rave parties,
but if you can't go back to the scene, will the cool babe you were at the
parties magically disappear, or will she still be inside you somewhere?

Hold on to the pride and self-esteem you remember from the parties, but
don't resort to club drugs to erase the nasty words of the Barbies. It will
be a hard struggle, but learning that you're still cool, no matter what those
girls say, shows how powerless the Barbies really are. Now you've devel-
oped real personal strength and confidence —and you don't need meth to
chemically brainwash you into believing it. A lot of the teens at raves are
in the exact same situation you are. Some of them are stuck on rolling
and are too addicted to stop the partying. But you may find some who are
willing to forage outside the rave scene to see if they can still feel good
about themselves without the drugs. If none of your rave friends can see
things the way you do, go to a teen AA meeting, and you'll find many young
people just like you. The friends you make there will share your desire to
stay clean and will also join you in the process of finding the cool, cute
babe inside each of you.
TAKING THE FIRST STEP
Before tackling the seemingly impossible notion of leaving your

friends forever, first tell yourself that you need some space from everyone
and everything associated with crystal, at least for right now. This is a much
easier time frame to grasp. It may mean this week, it may mean the next
several weeks. You cannot give yourself a definite date, but you know that
right now you are not able be around people or places that will tempt you
to use crystal. During that time, work on stopping crystal completely and
getting stronger supports that will help you stay clean —non-drug-using
friends, close family members, a drug counselor, a therapist, or a drug
treatment program.
Once you have detoxed from crystal and made these connections,
work on developing relapse prevention skills, so that if you see your old
friends, you will be better prepared to deal with tempting situations and
the strong feelings they will bring up. For example, practice refusal skills
especially when you know that old friends are going to try to get you to use.
Design your own mental exercises tailored to what situations you imagine
i you will be in, and practice them again and again to help you resist the
urge to use if you know that your friends will still be using around you.
WHAT IF YOU KEEP USING WITH YOUR FRIENDS?

If seeing your friends who use crystal or other drugs eventually pulls
you back into using, then you have the difficult task of assessing how these
people fit into your life. If you keep relapsing in their company, then they
are literally pulling you down a life-threatening spiral of addiction.
This does not necessarily mean your friends are "bad" people. It sim-
ply means that being with them results in an unhealthy situation that is
dangerous for you. Again, consider the asthma analogy — suppose you
had asthma and an allergy to cats, and you walk into a room with a litter
of five adorable kittens. They are cute and fuzzy, asking you for affection
and love. Despite how cute and affectionate they are, being with them
will trigger an allergic reaction and a severe asthma attack that could land
you in the hospital —you know this from previous experiences with cats.
The kittens are not bad per se, but being near them is dangerous, and you
need to stay away from them. This is how you should view your drug-using
friends —without judgment but with clear acknowledgment of the risk
they pose to you.

Once you are sober and are committed to stopping crystal, you may find
that with drugs out of the picture, you have a lot less in common with your
old friends than you had thought. Drugs and the activities associated with
them often form the fundamental bond that brings many people together.
While it may seem that there are other reasons that you are friends, drug
use may be the most significant reason. It's only when you stop using meth
that its role in your friendship becomes clearer. Which do your friends
seem more concerned about —protecting your health or the next time they
are going to do meth?
Finding "Sober Friends" Justin's story I
I
'
Justin became such a recluse, staying in his roonn doing crystal, that he
couldn't work, and he ran out of nnoney to pay for the drug, even though i
his friend made it and sold it to him very cheaply. He also started to
M become paranoid and suspicious about his friend. To avoid dealing with
him, he decided to try making his own crystal, using the recipe his friend
had found on the internet.

The state Justin lived in was cracking down hard on small, hidden
meth labs. One day two police cars drove up and uncovered Justin's secret
lab. They arrested him. and he was convicted of manufacturing illegal
substances.
Justin was sentenced to prison, where he was treated by the prison psy-
chiatrist for his psychotic paranoia and hallucinations. Justin's prison time
was shortened with the stipulation that he participate in a court-mandated
residential drug-treatment program in a town one hour from his home. After
completing the program, he was clean from meth for two years.
Justin returned home to an empty house— his mother had moved in
with a new boyfriend. He resumed his life where he had left off, working
at a gas station part time. He was happy to see his old friends again, no
longer paranoid and suspicious of them. However, they were still using
meth, smoking it to while away their free time. When he first saw them
high after he had been clean for so long, Justin didn't like what he saw
and realized how far he had let himself go. He had an even stronger
resolve not to start crystal again.
After two months back at home, Justin was still clean. He wanted to stay
away from crystal, but it was difficult. He didn't know anyone else to hang
out with, because his community was so small— it was difficult to meet new
people that he liked. With only a part-time job to keep him busy, he soon found
himself in the same dilemma as before— having nothing to do, he felt bored
and "useless." He started having strong memories of the excitement he felt
when using crystal— not just mental images but even bodily sensations. All
he could focus on was how ever^'thing felt so vibrant and interesting when
he was high. Though he also recalled the anxiety, paranoia, and malnutrition
that he had suffered, it seemed like a faded memory in comparison to the
strong, visceral feelings of how good it felt to be high. Eventually the draw
became overwhelming, and one day when he was hanging out with his friends
while they were smoking crystal, he asked them to pass him the pipe. They
were surprised but happy to have their old friend back in the fold and relieved
not to have a teetotaler hovering around them, making them feel judged and
uncomfortable about their drug use.

I Justin started with just doing crystal on his days off fronn work, but
^ within a month he was snnoking every day again, and soon his paranoia
I and hallucinations returned. Fortunately, he recognized what was hap-

pening to hinn, especially when he started hearing voices again. He still
^;
had the telephone number of the drug treatment facility he had gone to
after prison, and he called his old counselor. Justin returned to rehab.
During his second rehab, Justin had even more material to talk about
with his counselor and with the groups, looking at what exactly caused
him to relapse. He discussed his boredom and the lack of structure to
most of his days, which intensified his cravings. He complained about how
difficult it was to find friends who didn't use meth. making excuses for
why he kept hanging out with people who were smoking right in front of
him. Even though he had talked about these same issues during his first
rehab, he didn't really connect with the discussions until he experienced
them firsthand when he returned home.

During Justin's second rehab, he had more motivation and insight, and
he worked closely with his counselor to develop a plan for what he would
do after discharge: he realized that even though his community was

small, there were places in his town where he could find potential friends.
He had dismissed those people because he assumed that because they

were not drug users, they must be boring. But now they seemed like
safer options, which was comforting as he began to understand that his
old "interesting" friends were actually dangerous to him. As paranoid and
psychotic as he had gotten, his friends kept smoking meth in front of him
while he struggled not to use so that he would never have to hear those
terrifying voices in his head again. He left rehab with a new desire to make
sober friends with whom he could stay clean.
Justin found an AA meeting that was in a town one hour away. There
were no CMA meetings in his area, but a group recovering from alcohol-
ism was close enough — he could still talk about addiction and get support
from other people trying to get sober He was surprised to find another
person from his community at one of the meetings, and they become
"sober friends." Now, when Justin felt lonely he did not have to call his
old drug-using friends anymore.

Even though the AA meetings were an hour away by car, he went to the
meetings every day that he was not working at the gas station, and even
on some days after he finished work. He had a more regular schedule,
and life didn't seem so formless and lacking in direction. While he regret-
ted not having a better job, he felt he was working hard to move forward,
and he felt more empowered. He had something to feel proud about.

Justin still struggles with bouts of strong urges to use crystal, especially
when he feels disappointed with himself and frustrated with his life. However,
whenever he feels this way, he calls his sponsor or one of his sober friends, j
When cravings are intense, he goes to town and waits for the next AA meeting.
None of his old friends cook meth anymore because all the local basement
labs were shut down by the police. Still, Justin heard that crystal was available
in town from an outside source, but he has resisted asking about it so that
there is no possibility he can find any crystal if his temptation to use becomes
irresistible. Eighteen months have passed since Justin last used crystal, and
he IS still struggles with occasional cravings, but he "fights the good fight" and ;
remains motivated.
ASOCIAL EXPERIMENT
See what happens when you spend time with your friends and do not use
drugs. In this experiment, I refer to any drug except alcohol. That includes
Ecstasy marijuana, cocaine. Special K, and crystal, as well as any other
illicit substance or even prescription medications, such as OxyContin, that
are not used according to the medical instructions. Consider yourself the
investigator of this small sociology' experiment. The purpose of the study
is to obsenê what happens to a group of friends who regularly use club
drugs together, when one person decides that, for health reasons, he or she
wants to stay away from all drugs. During the experiment, the designated
sober person steadfastly refuses all drugs for two weeks (at least two cycles
ofweekend partying), while the others are free to choose whatever they
want to do.
You are the sober person in this experiment —remember that you must
remain completely sober for the experiment to work. Focus your attention
on what happens among the group members while you remain sober. Note
but try not to dwell on the nagging feeling that if you just did a little crystal,
or even just a tab of E or a bump K while the rest of your friends were
of
partying, your interactions would be much more comfortable. In fact, the
discomfort you notice is one of the things you are trying to understand in
this study. This exercise requires you to step outside yourself and look at
the entire group, including yourself, as if you were an outside observer.

This will give you a more accurate picture of what happens to the group,
and by intellectually removing yourself from the situation, it may be easier
to emotionally step back, rather than to get caught up in the powerful
emotions that could push you back into using drugs. If you are able to
complete this exercise, you will learn important things about yourself and
your friends, and you may make some significant changes in your friend-
ships and your life.
If you are fortunate during the time that you remain completely sober,
you may discover that there are many non-drug-related activities that you
enjoy doing with your friends. Maybe you already knew this, but perhaps
your friends realized they could enjoy themselves together without neces-
sarily using drugs. Your friends must also be sober when engaging in these
activities with you. Participating in activities and connecting with each
other without any drugs, you may form deeper, more meaningful friend-
ships that are not distorted by chemical highs —anyone can be fun to
hang out with if you take the right drug, but if you need drugs to tolerate
someone, perhaps that's not a good person for you to be around.

On the other hand, you may find it difficult or awkward to relate to
these friends without using drugs. Some people in your social circle may
be uncomfortable, feeling that you are judging their drug use: "If he thinks
bad for him, he must think I'm bad for doing it." You may also find
it's
some friends who keep pushing you to do drugs, even after you've told
them repeatedly that you don't want to. After so many refusals, why do
they keep pushing? Do they have any respect for your wish to stay clean?
How important to them is your health, which you are trying to protect
from drug use? Or do they even care about your desires, clearly repeated
several times? How do their concerns about you compare to their need
to get you to do drugs with them? Some people need to have others use
drugs with them because it makes the act seem more acceptable they —
are helping themselves feel less guilty about their own drug use. Does this
need to justify their own drug use overshadow their concern for you and
their respect for your wishes?
You may find that when you take drugs out of your friendships, there
is little else left that you actually have in common. When Boys Fly is a
documentary that follows four very different gay men as they go to the
same circuit party. One young man promises his roommate at home that
at the circuit party he will not use drugs because, despite serious problems
with drugs in the past, he is determined to prove that he does not have
a problem with drugs, and that circuit parties are not just about drugs.
They are spiritual and communal experiences for gay men. Before arriv-
ing at the party, he tells the camera about his "closest friend," a slightly
older man who he says understands him deeply, better than anyone else
in the world. The friend is a "circuit buddy," someone he only sees when
he goes to circuit parties around the country. The two run into each other
only briefly every couple of months at circuit parties when they are both
high. Nonetheless, the earnest young man firmly believes the two are soul
mates. After a long, frustrating search among thousands of men, he finally
finds his friend. The young man is sober and jumping with excitement but
the friend is almost mute, staring with a smiling yet empty expression, with
glazed eyes as large as saucers. It is clear to the viewer that something does
not match. While the young man is jumping with glee, his 'closest friend
in the world" appears frozen, almost without any reaction. The viewer
wonders what actually makes these two men so close. Only after the young
man breaks his promise and starts using drugs do the two "friends" relate in
any significant way —the old friendship is rekindled. So is it really friend-
ship, or are drugs the real bond that connects these two?
When you consider the friendship in this documentary, you may realize
thatsome of the people in your own life may just be drug friends. When
you first group
join a of partyers, big differences may seem like a positive
thing
— "Wow, developed I've a group of really diverse friends from all dif-
ferent backgrounds!" However, when you try to sustain some of these rela-
tionships without drugs, it becomes clear which relationships are based on
drugs and which have real substance. Consider carefully how you define a
"friend." Then think about which people in your group of partyers fit this
definition. If these people are not really your friends, and they are putting
you at risk for relapsing, you need to let go and move on.
Socializing in circles of drug-using friends makes it easy to always have
people around you. Drug users consciously or unconsciously find each
other, quietly assessing people and asking themselves, "Is he one of us or
not? Does he even know what Tina is?" The ease of finding drug friends is
extremely attractive because it wards off loneliness. The temptation to fall
back on this group can be strong if you are alone and trying to find a new
group of friends who are sober. Forming friendships based on something
real can take much longer than friendships based on drugs. But patience
and hard work pay off because you will develop real friendships with
people who have a real connection to you, rather than an artificial sem-
blance of a friend that is really just another excuse to use drugs, disguised
in human form,
LETTING GO
Letting go of drug-using friends is a difficult but necessary task for suc-
cessful recovery. If these people are your primary friends, you are making a
tremendous sacrifice, much more than just crystal —you are giving up your
main social network and your usual social support system.
Gay men living closeted lives in homophobic areas of the country may
look to their drug-using club/circuit friends as their supportive brothers
and their only connection to the gay community. It may be difficult to
believe that they can find many other gay men who are sober, whether
they simply do not use drugs or are ex-partyers like themselves who are in
recovery. In fact, sober friends would likely be even better supports, pos-
sibly being more available to you when you really need help, not just when
you are looking to have fun and party.
Drug users in general, male or female, gay or straight, are part of
a drug culture, and the underground nature of illicit drug use gives drug
users a common bond. For those drug users who don't feel connected to
any other group, the sense of belonging to the drug community can be
difficult to let go.
For people who live in small communities in rural areas, where

meeting strangers is rare, the prospect of giving up the few close friends
they have now is even more daunting because it seems as if there may be
no one —sober or not — to replace them.
Regardless of which group you fall into, the idea of cutting off
contact with your main social group can be frightening. For this reason,
it is extremely helpful to get connected with treatment, whether with a
therapist, a drug counselor, a twelve-step group, or other support groups.
Your sober network will provide you with supportive backup while you
test out your old friendships with your new sober life, help you to assess
whether you need to end certain harmful friendships, give you the skills
and courage to break away from old destructive relationships, and be there
for you to give you support when you finally let go.
Letting go of your old friends can feel incredibly lonely In contrast to

having a large group of meth-using friends who were always available to
party, you may feel extremely alone during your search for new friends.
However, building a new circle is very possible, though it requires some

effort. If you are recently coming off crystal, you may feel down, socially
withdrawn, and not at all interested in reaching out to new people right
now. Others may crave connection and want some handholding through
this difficult stage of early sobriety. No matter what your situation, you
should reach out for support because remaining isolated puts you at risk
for relapsing. If you feel withdrawn right now, at the very least, use your
sober treatment supports (AA, CMA, drug counselors, therapists, and so
on) to maintain healthy contact with the outside world while you gradually
develop a new circle of friends.
YOUR NEW FRIENDS

The notion of finding a whole new group of people to get to know,
trust, and open yourself up to, as well as finding people that you would
actually enjoy spending time with, sounds monumental if you are starting
from scratch. However, this is something that most people go through,
and they do it successfully. This is a normal part of life, even outside the
addiction world. Take for example people who move to another town in a
distant state for a new job. The initial transition is difficult, but eventually
they find new friends.
Let me reemphasize the importance of utilizing your relapse preven-

tion network to maintain some healthy social contact during this period
so you do not feel completely cut off. Loneliness and boredom can be
strong triggers that draw you back to meth. In addition, the frustration of
feeling socially disconnected when you are used to the ease of old friends
constantly within reach will create a great temptation to go back to your
old group.
For the time being, CMA, other twelve-step organizations such as AA
or NA, or a non-twelve-step support group can be your temporary social

circle. A therapist can ser\ê as a confidant with whom you can share
your difficulties as well as your triumphs and joys. A twelve-step spon-
sor can be there for you to call at any time if you need someone to speak
to immediately. You may find that some of the people in this "surrogate"
social circle become good friends, sharing many things in common with
you, especially the difficult task of sobriety and all the obstacles that come
along the way.
The process of making new friends may be gradual and take a long
time. As frustrating as it may feel, this is actually a great opportunity to
significantly improve your life. Take the time to think about what you really
want from friendships, and make a list of what characteristics are most
important to you. Your experience with ''drug friends," an extreme version
of fake friendships that happen to most people, taught you a lot about what
makes a friendship satisfying and real. If you are prepared with your list of
what you expect of real friends, whenever you meet someone, you have a
better ability to assess how this person may fit into your life, and you can
decide who you want to incorporate into your social network. Gradually,
you will fill your life with healthier and more meaningful relationships.
Here are a few questions to think about when considering whether
someone has the potential to be the kind of friend you want in your life:
M Is the person interesting?

4 Do you have any things in common —experiences, hobbies,
sense of humor?
5 Is this person different, but in areas that you would like to learn
more about?
J Is this person different, but is interested in learning more about
you?
Is this person so different that you both find it difficult to under-
stand each other?
Is this person caring and sympathetic?
I Can this person listen or is this person mostly a talker? Does he
or she have the capacity to really listen when you need someone
to talk to?
Does the person ask about you, as well as talk about him- or
herself?
M Does this person have the capacity to care about you, sympathize
with you, or support you emotionally if you need help? Or does
the person keep changing the direction of the conversation back
to him- or herself?
Does the person use drugs or is the person in recovery?
Does this person seem like he or she can handle knowing that
you are in recovery?
, . Is this person trustworthy and dependable?
These are only a few examples of questions that you might ask. Think
of other questions about the qualities that are most important and mean-
ingful to you.
Making new friendships may not be as quick as it was when you were
using crystal or other party drugs, when the common bond of the drugs was
what brought people together easily. Dr. Edward Khantzian, a well-known
psychoanalyst and addiction specialist, believed that the actual friendship
was between the addict and the drug. Cijstal was your real friend, and
the people associated with it were objects that you and "Chrissie" used
to enjoy your time together. In this light it is even clearer why it is so dif-
ficult to make new friends — it is as if you were married to someone for
several years, during which you were no longer dating —the relationship
turned bitterly destructive, so you divorced, and now you're back on the
dating scene. But it's hard to put yourself out there and meet new people
again. You feel lonely, awkward, and out of practice in the social scene.
Also, when you meet new prospects, sometimes you remember the best
things about your ex, and new relationships seem dull and dissatisfying in
comparison. Divorced people often have rough starts, but eventually they
start meeting new people again.
Sober people who would make good friends may be right under your
nose. Non-crystal-using friends who had been in your life but who fell by
the wayside during your crystal years may still be around, and they may
be glad to hear of the return of the old friend they thought they had lost
to drugs. Important relationships with family members may have grown

distant, but hopefully not too far to reach and try to reconnect.
The Eighth Step in twelve-step programs is make a
to list of all persons
one has harmed, and become willing to make amends to them all. The
Ninth Step is: "Make direct amends to such people wherever possible,
except when to do so would injure them or others." "Persons we have
harmed" include those that you may have rejected and broken ties with
because of your addiction. The Eighth and Ninth Steps remind you of
important people you may have lost as a result of crystal. They confront you
with the ugly truth that your addiction damaged and potentially destroyed
those relationships, and they give you an opportunity to repair them.
Developing new friendships now may feel different and much more
difficult than earlier experiences because instead of adding new friends
to your existing group, you may have to start completely from scratch.
Keep a list of ideal qualities in mind when forming new friendships, but
also remember that these qualities are not always apparent the first time
your meet someone. You may have to meet a lot of people before you find
any that seem even remotely "friend-worthy" according to your criteria.
However, even with the "right" people, it takes time to get to know each
other and to develop a trusting and caring bond —no one can meet all the
requirements of your list at first meeting. Keep yourself open to different
people, even those you might not have considered in the past, and try to
stay optimistic. While you are getting to know people, always keep your
wish list of criteria in mind. You may even decide to make changes as
you meet more people and further clarify your definition of a satisfying
friendship. If you get the sense that the person uses drugs, say good-bye
immediately. You are in recovery and your health is too important. No mat-
ter how interesting that person seems, he or she poses a great risk to you.
The crystal-craving part of your mind may sense the possibility that the
person is a drug user, and unconsciously the person may seem even more
appealing, because you know that spending time with that person will lead
to using crystal again. Before this happens, if you start to feel this smallest
possibility that the person uses drugs, stay away.

When first stopping crystal, you may not feel very sociable, especially
during the acute withdrawal, which usually occurs one to seven days after
stopping. However, depression and social withdrawal can linger for several
weeks thereafter. If you feel this way, give yourself a break and for now, use
your recover}' network for social support and connection. After a month, if
you are still feeling lonely but aren't getting yourself out of the house, force
yourself out there. If you are really feeling stuck, see a psychiatrist to see
if you are clinically depressed. Some symptoms of a biological depression,

aside from low mood, include social withdrawal, feelings of hopelessness,
low energy, and poor motivation — all of which can be keeping you stuck
in a rut, preventing you from making new friends, and putting you at risk
for relapsing on crystal Appropriate treatment for depression can get you
back on your feet and starting to rebuild your social network.
WHERE DO I FIND NEW PEOPLE?

Keep yourself open to meeting people but try not to search so aggres-
sively that your search becomes a hunting expedition. If you are relaxed
and open to meeting new people, you can encounter potential friends
in any place and at any time —on the street, when you are shopping, at
work —any place you find yourself. Places to avoid meeting friends are
wherever you know or suspect there is drug activity — bars, clubs, circuit
parties, sex parties, raves, and so on.

In addition to relying on random events, you can be proactive in meeting
people. Go to social events and parties with sober friends. Attend sober
events held by twelve-step groups. Find out about organizations and activ-
ity groups in your local area that interest you, whether it is a pottery class,
a hiking group, a book club, or a continuing education class, particularly

classes that are interactive, such as conversational language groups (many
are designed as social events) or studio art courses. Try several different
avenues until you find one that really feels enjoyable. At the very least,
even if you don't find a new friend, you will be doing an activity that inter-
ests you. The fact that the other people at those activities chose to be there
means that they share at least one interest with you. Hopefully there will
be people there that you may also like as friends.
Another avenue worth exploring is volunteer work. Find a cause that you
believe in, whether it is helping the homeless, fighting the HIV epidemic,
supporting your favorite political cause, helping to organize the local Walk for
Breast Cancer, or whatever is meaningful to you. Picking a cause that holds
strong personal significance to you may help you meet others who share not
only an interest but a passion —perhaps the shared passion will reveal even
more similarities that will make the person seem more interesting as a friend.
Making a positive interpersonal connection and doing something personally
meaningful are both activities that most consistently stimulate the parts of
the brain involved with happiness —both psychologically and physiologically,
you are improving your mood and your experience of living sober.
Just a side note about volunteer work: volunteering is wonderful because
at the same time that you help others, you also improve yourself. Being
productive in a way that clearly benefits others is associated with improved
self-esteem. Additionally, by helping others, you cognitively redirect your
attention away from yourself and your own troubles, and you remind
yourself that other people are suffering as well. Many people in recovery
choose to volunteer or even devote their careers to addiction services and
helping other addicts to stay sober. They find that this kind of work helps
to keep their own sobriety under better control by letting them witness the
dangers of addiction without having to relive it themselves. It also requires
them to constantly think of innovative strategies to help other people stay
sober, and shows them the positive results of sobriety in the people that
they help. Addiction work keeps one s relapse prevention skills honed and
provides strong motivation and reinforcement to stay clean and sober.
19
CRYSTAL AND SEX:

If Sex on Crystal So Amazing,
Is
Is It Possible to Enjoy Sex Without It?
SEX ON CRYSTAL
For many crystal users, sex is their primary activity when they get high.
One reason for such a close association between this particular drug
and sex is that they both stimulate the dopamine-mediated mesolimbic
pathway. As discussed earlier, stimulating this pathway is nature's way of
tricking animals to repeat behaviors, such as sex and eating, that help the
animal, and ultimately the entire species, survive. Therefore, when the
mesolimbic pathway is so powerfully overstimulated by methamphet-
amine, the drive to have sex is also stimulated to a pathological extreme.
Libido and sexual pleasure on crystal is exponentially more intense than

sober sex because the mesolimbic pathway is stimulated to an unnaturally
high degree that it was never meant to reach. When they are high, people
spend hours or even days searching for sex, having sex, or masturbating.
The drive can feel like an insatiable hunger. Crystal makes erections dif-
ficult or impossible to achieve for most men, so in the past, users were
usually the recipient of anal sex (aka the ''bottom"). Since the advent of
Viagra and similar medications that facilitate erections, men on crystal can
now perform both the penetrative and the receptive role in anal sex. Since
both partners are now able to use crystal and have equally long-lasting sex
drives, the duration of sexual activities has increased significantly, and sex
hookups or sex parties can last from hours to days.
Within the gay community, sex clubs have seen a dramatic change in
sexual behavior. Many patrons now stay at the clubs much longer than in
the past because they remain high on crystal for long periods, and during
extended binges some patrons stay over twenty-four hours. Some sex clubs
have resorted to strictly enforcing time limits when patrons must leave or
pay another entrance fee. In the past, it was hard to imagine people staying
for more than eight hours in a sex club, but as long as there is a supply of
crystal to fuel the sex, time can be almost limitless.
Safer-sex practices have also changed. Despite the dedicated efforts of

outreach workers to educate people about HIV-transmission and provide
free condoms, increasing numbers of people are having sex without con-
doms. Many patrons in gay sex clubs report that some men refuse to have
sex with them with a condom. Even though the threat of HIV, hepatitis,
and other sexually transmitted diseases are well known, concern about the
health risks seems negligible compared to the compelling urgency to have
more sex. When experiencing intense sex is the most important objective,
"condoms just get in the way."
Here is an example of a personal ad on an Internet sex site for gay men

that illustrates how crystal can affect the sex drive:
Looking for guys between 18 and 50 hight and weight pro-

portionate that PNP/SLAM occasionaly. preferably guys that
"SLAM" Cause after I "SLAM" all 111 wanna do is suck cock and
get fucked over and over draining load after load of cum into my
ass and mouth!!!
[PNP = "party and play" —using crystal and having sex; SLAM =
injecting drugs intravenously]
The following anecdotal report from a suburban emergency room is
another illustration of how disturbingly pathological sexual compulsions

can be when fueled by crystal:
CRYSTAL AND SEX I 249
Kevin is a twenty-seven-year-old heterosexual male who was taken to
his local emergency room by his roommate. He was extremely agitated

and presented with bleeding abrasions (worn-down skin) on his penis.
I
Because he was so agitated and his pupils appeared dilated, a urine drug
I
i
screen was performed and tested positive for methamphetamine. He
j
:'
admitted to the ER physician that he had been smoking meth and then j
masturbated for six hours, resulting in serious abrasions and tears in the
j
skin on all surfaces of the shaft of his penis. Prior to that evening, the \
patient had only used methamphetamine intranasally, but that night was
his first experience smoking it. ;
Prior to the night of this ER visit. Kevin used to snort crystal alone in
his room because it often made him sexually preoccupied. His usual rou-
< tine was to masturbate while watching pornographic videos for a couple
of hours. Then if he still felt sexual, he would go to a bar to try to pick
up a woman for sex. He was curious about smoking because his friends
recently changed from snorting to smoking, and they said it was so much
better. Because Kevin became so sexually preoccupied just from snort-
ing, he wondered how he would feel smoking meth, but was terrified of
embarrassing himself in front of his friends. They didn't become fixated
; on sex with the same intensity as Kevin. Usually while smoking they sat
around joking until they became restless enough to take their cars to a
large empty parking lot. where they drove wildly m figure eights.
That night Kevin felt particularly curious and borrowed his friend's
;
glass pipe. Alone in the privacy of his room he tried smoking meth for the
•
'
first time, and he found his sexual desire was far stronger than he had
ever imagined it could be. He had taken 200 mg of Viagra (four times the
J
average dose) so that he could maintain an erection while masturbating.
He was engrossed in watching his video, stopping every fifteen minutes
I
^ take another hit from the pipe. After each orgasm, it was more difficult
j to achieve the next, so his masturbating became more and more aggres-
I
sive. Kevin was using a lotion containing alcohol, and some time after \
his third orgasm, he felt a burning sensation on his penis. He realized -
I
that they were little patches on his penis that were irritated from the »
constant rubbing. He just changed to a different lotion without alcohol \

r
1
and resumed where he had left off. After his fifth orgasm, it was extremely
difficult to achieve another, but he compulsively smoked more crystal,
and masturbated with even more determination, trying to have one more
orgasm. After a total of six hours of smoking and masturbating. Kevin ran
out of meth. and over the next ten to fifteen minutes, the compulsive drive
to masturbate gradually waned. He felt increasingly tired and irritable,
and he was becoming more aware of pain all over his penis. He looked
down, and saw that the lotion on his hand and on his penis was streaked
with blood. He had been so preoccupied with watching the video and try- f
ing to have an orgasm that he didn't notice that the irritated spots were
starting to bleed or that he'd rubbed off some superficial layers of skin,
leaving some patches of skin pink and raw. An hour after he had smoked
the last of his meth. the discomfort in his penis had turned into excru-
ciating, burning pain. When he started screaming, his roommate ran in,
dressed him. and rushed him immediately to the emergency room. I
While these reports sound disturbing to the outsider, people who

combine crystal and sex often report it to be one of the most amazing
experiences in their lives, and they long to repeat it. For some people,
crystal sex feels so amazing that, in comparison, sober sex seems dull
and unfulfilling. Many gay men start using crystal as an occasional way to
spice up sex. but they find themselves relying on it more often, and some
of them reach a point where they are unable to have sex without it. If you
are trying stay meth-free, but crystal had become a necessary part of sex
for you. it will be an extremely powerful trigger Because sexual desire is
a natural occurrence, this trigger is unavoidable, so the issue of sex and
how you will deal with it must be thoroughly addressed.

|
BIDDING FAREWELL TO SEX ON CRYSTAL
Life without crystal means life without crystal sex. It's that simple.
Many people who used to combine sex and meth recall intense, aggres-
sive, compulsive, limit-pushing, cathartic, nonstop-pleasure sex marathons

that they long for again, But having crystal sex means putting meth in
your body at least one more time, something you can't afford to do. Once
that happens, you know it won't be just a one-time indulgence. It can
quickly spin into a full relapse that brings you right back into the full grip
of addiction.
If your mind keeps going back to crystal sex, don't try to ignore it and
pretend it never happened. The memory only fights harder to come back
until you acknowledge it, and it may grow in power as the memories
become even more idealized, like a little child calling out to you, jump-
ing up and down, screaming louder and louder because he can't get your
attention. It's all right to acknowledge this —but as a very special memory.
You can recall it as an amazing time, like a trip to Antarctica with breath-
taking sunrises over colossal glistening snow peaks, unlike anything you
could see elsewhere on this planet — it was a grueling trek to get there,
extremely expensive to arrange. You drove, camped, and hiked through

temperatures 20 degrees below zero with fifty-mile-per-hour gusts or wind
that gave your face painful burns. Your body and soul took a tremendous
beating. But when you reached your goal, your experience of the place
was literally breathtaking and filled you with an amazement you had never
felt before. It was a long, difficult, and costly journey for an experience
that very few people can ever have — or even imagine. What an amazing
memory you have to carry with you for the rest of your life. But it was a
once-in-a-lifetime event, and you can't go back. That realization does not
diminish the amazing things you experienced. In fact, it helps to put them
in perspective —the immense physical effort and financial cost to get there
remind you that this is a place not meant for humans to see. That makes
the memory that much more precious —the realization that you saw the
unseeable. You remember the amazement you felt, and you hold on to the
beautiful memories, but you also know that you can never go back.
Crystal sex is like this amazing journey. Acknowledge the powerful,
amazing pleasure you felt, costly in so many ways, to experience something
that felt so amazing because the human brain was never meant to feel
that. Unlike most people in this world, you were able to experience it and
have incredible memories. But you can never go back. This is an important
admission you need to make to yourself, because any hidden fantasy that
one day you will have crystal sex again is a seed that can grow into an
uncontrollable craving and a relapse.
When you are just starting to quit crystal, if sex is a significant trigger
for you, then you may want to hold off on having sex for a while. This does
not mean that you will never have sex again. Just for now give yourself a
chance to work on basic recovery skills before you have sex again. Try for
a month and see how well you do. It may take several months before you
feel ready to tackle sex without crystal and feel safe that it will not lead to
a relapse. Many people in CMA feel that if you are not currently in a rela-
tionship, it's best to try to stay away from sex for an entire year. For people
who used to have frequent binges of crystal sex, who spent every weekend
getting high while searching the Internet for sex, or who regularly used and
did some other sexual activity, making a commitment of no sex for a year
helps them to break those other habits that go along with crystal, which
on their own can be addictive. Since sex is such a powerful trigger, those
people may do better working on staying sober, learning relapse prevention
skills, and practicing their ability to resist smaller urges before moving up
to the challenge of sex, which will be tough, but eventually possible, and
definitely enjoyable.
If one year sounds too long to you, set a shorter time limit that sounds
tolerable for you, and see how you feel. At the end of that time, if you sur-
vived it and you think you would benefit from a little more time, then you
can choose to wait a little longer. It is a good idea to give yourself a break,
but set your time limit in bite sizes that you can swallow.
WHY REGULAR SEX SEEMS SO POINTLESS

During initial sobriety, sex just doesn't feel as good as it was when you
did it with crystal. It's not just that everything in life is dull — sex in particular
has lost its luster. The physiological reason is that after so much repeated and
intense depletion of dopamine from the brain-reward circuit, the fibers in this
pathway which are associated with pleasure during sex, are damaged. Trying
to stimulate the circuit again with sex just doesn't create the same charge it
used to. This is true, not just for sex, but for many other activities that used
to give you pleasure. Most of these things will improve over time. Your brain
will gradually replenish its stores of dopamine, and some of those particular
brain cells may recover, though unfortunately, some of the damage may be
permanent. Lack of pleasure is worst right after stopping crystal. However, by
one to two weeks, a good degree of your ability to feel pleasure should return
as your dopamine stores are refilled. Recovery from damage to your brain cells,
however, could take months to years.

Even after the initial crash, when most things in life feel better, sex still
may seem empty. While this may be due in part to the neurological expla-
nation described above, much of the difficulty is that, in comparison to sex
on crystal, even imagining regular sex seems so dull. Figure 19-1 shows a
scale of sexual pleasure experienced at different points in your life, from
before your first sexual experience, through the time you were using crys-
tal, and all the way to the time you are long into sobriety. The shaded area
represents the normal range of pleasure that your brain experiences from
different activities in life. Zero reflects no pleasure, and 10 is the highest
pleasure that you normally feel, what should be extremely satisfying, such
as having an orgasm.
Figure 19-1 . Scale of Sexual Pleasure
Think back to the first orgasm you ever experienced, whether you were
masturbating or having sex with another person. It was so new and intense
that it was probably off the pleasure scale compared to anything you had
previous experienced, probably scoring a 1
5 — off the charts if your normal
pleasure scale is 0 to 10. That is why you very likely wanted to have an
orgasm again. After repeating sex several times, it stopped feeling so new,
but it remains extremely enjoyable, remaining at the top of your normal
scale of pleasure, scoring your maximum of 10.
The first time that you had sex on crystal is similar to the first time you
ever experienced an orgasm — so high that it is off the chart again. However,
it is likely much higher than 1 5 because it is a physiological state that your
brain could never reach on its own. On your scale of 0 to 10, sex on crystal
would score a phenomenal 30 —way off the charts. Looking at your previ-
ous experiences of sober sex, what seemed completely satisfying as a 10
now appears so low in comparison that it is like looking at a 0 —bleak and
empty. If it is so lackluster and boring, why would you want to do it again?
Nonetheless, the drive to have sex will eventually return because it is a part
of the brain-reward circuit. Almost inevitably, if sex became closely tied to
crystal for you, sex will become a strong trigger for crystal because regular
sex will likely not satisfy your sexual appetite at first. After repeated experi-
ences of intense sex with crystal, the first several attempts at sober sex may
feel like a pale shadow in comparison. However, this is from the perspective
of a distorted comparison, from an expectation of pleasure that your brain
was never meant to experience. Regular sex may feel like a 0 at first, but
with time, it will feel enjoyable again and work its way back up to 1 0. It will
never be as intense as the 30 of crystal sex, but it will feel good again and
can return to being one of your great pleasures in life.
RELEARNING SEX
— —
Having sex again sober sex may require a process of relearning to
make it satisfying again. Take it slowly and monitor your expectations.
Remember, this is not crystal sex, so you should not expect it to be the
same. If you rush yourself or become frustrated that you are not having the
same experience, you may quickly turn back to the drug.
When you have sex, it is important not to have it in the same settings
or situations in which you had crystal sex. You need to have different
environmental cues, so that you do not trigger strong urges to use again.
Stay clear of sex clubs, sex parties, telephone sex lines, Internet sex sites,
any other places and activities that remind you of meth, or places where
you know people are likely using it. Unless it is with your partner, do not
have sex with people with whom you used to have crystal sex. Remove
as many reminders of crystal sex from your life as you can. Even though
you are not a virgin, imagine yourself starting something new and fresh.
Detach yourself from all your older associations to sex that were in any
way associated with crystal.
When first starting to have sex again, try to have it with someone who
is not a random sex-only hookup. Set a rule of not having sex the first two
times you meet someone, so you can get to know the other person and
hopefully form a connection even before sex. Then when it's time to have
sex, take your time and go slowly. Do not jump into the sex aggressively like
a tiger pouncing on its prey — thatis too much like the aggressive aspect
of crystal sex, and you are exploring something different this time. Also, if
you start the sexual encounter as you normally would with crystal sex, you
start setting up expectations that it will feel like crystal sex. But it can't.
Doing this sets yourself up for disappointment and frustration, and creates
a trigger to go back to crystal.
For the relearning process, think of this as completely different activity.
Focus on every little physical sensation: appreciate the feeling of holding

the other person's hands and take in the sensation of skin rubbing against
skin on the rest of the body Wrap your arms around each other and gently
hold each other, or if it feels good, enjoy a close and tight squeeze. How
does it feel?
If you are both big kissers, don't just dive in as if you're fishing for pearls
with your tongue in someone's throat — take your time and appreciate the
the light touch of someone's lips against your own, or even the feeling
of someone being so close that you feel the other person's warm breath
against your lips or face, even before your lips ever touch. Again, go slowly,
and take in what ever warm or happy emotions you may be feeling along
the way. These are all the more intimate aspects of sex that trigger parts
of your brain outside of the brain-reward circuit. They are more related to
the parts that are activated by "connection" and "personal meaning," which
have been found to be most closely associated with happiness. They are
often forgotten or thrown by the wayside during the aggression of crystal
sex, as the behaviors related to the brain-reward pathway crowd out most
other things. Many people who have forgotten about the intense pleasure
from the other parts of sex now realize that while sober sex will not be the
same as crystal sex, it is not just a pale, weaker version — it is something
different that has its own values that crystal sex will never have.
The first couple of times you have intimate physical contact with
another person, restrict yourself to nongenital contact, even if you want
to go further. Fully explore the intimacy and let the natural desire for sex
build. You may find that you are much better able to feel an emotional
pleasure that you may have been missing with crystal.
Many believe that crystal helped them feel "connected " to others when
they had been feeHng isolated. However, this is an illusion. While you may
have been physically connected to someone while having wild, aggressive
sex, it was the meth and the sex that you were really emotionally connected
to, not the person, who could have been almost anybody. Consider how
crystal was able to make almost anyone seem appealing, including people
that you ordinarily would never have considered having sex with. Now
you have the opportunity to experience a genuine connection to another
person, and this is a wonderful feeling that crystal is not able to give you.
Sober sex will begin to have its own positive associations, distinct from
your memories of sex on crystal. However, be cautious. While relearning
sober sex, if you slip and start to incorporate drugs into your sexual routine
again, you are just contaminating your meth-free world with associations
to meth and making the possibility of relearning satisfying sober sex more
difficult.
When you are comfortable and enjoying the intimacy of sex without
drugs, you can start to incorporate other things into your sexual activity to
make it more exciting. Communicate with your partner about what feels
good, or ask what your partner wants. Try role playing. Experiment and
have fun. However, as much as possible, avoid activities that explicitly
remind you of crystal sex.
While you will always have memories of sex on crystal, the desperate
need to have it become less intense. Memories may return in
will gradually
flashes, but the flashes will become briefer and less frequent if you do not
succumb to them by relapsing. Sex will eventually become the wonderful
thing in your life that it had been before.
A SPECIAL NOTE FOR PEOPLE WITH

SEXUAL COMPULSION/ADDICTION
People who have sexual compulsions and addictions likely had prob-
lems with sex even before crystal, though the drug can exacerbate the
problem. These people should seek additional counseling to specifically
address sexual compulsions, in addition to treatment for crystal addiction.
Unless these compulsions are addressed, it will be much more difficult to
break the associations of crystal and sex, because the compulsive aspect
of this kind of sex is neurophysiologically tied to the pathways stimulated
by crystal. You may need to address sex on a much slower time frame when
trying to reintegrate it into your life.
One aspect of sex that is discussed above, the intimacy aspect, takes
away the clandestine, secretive, and forbidden aspects of sex that is often
part of the high in sexually compulsive behavior. Some psychologists
theorize that, for sex addicts, the compulsion to have so much sex is an
unconscious reaction against another unconscious force —the ''superego"
or conscience telling you that sex is bad. By going slowly with one partner
and exploring intimacy and deep connection, you may be able to experi-
ence the sex not as something bad but as something beautiful, and this
may lessen the desire to pursue sex compulsively. However, you should
work with a specialist on this coaddiction to make sure you can keep it in
control.
p RT
6 !
SPECIAL TOPICS
Topics are presented here for individuals with specific concerns in addi-
tion to the basic treatment program information presented. This is a small
list of additional questions out of many that you may have about your
own situation. encourage you to think about any other questions and to
I
be active in your search for answers. The process of doing and learning
are important in your own recovery and in helping someone you love.
More information is always helpful, being active in your pursuit of knowl-
edge keeps the motivation alive, and any opportunity to understand the
things that affect your life is important. After this section, there are
resources listed in the appendices that may be able to assist you in pursing
answers to more questions.
Topics:
• What if you slip and use crystal? Disaster and failure
versus a learning opportunity and a step in the prog-

ress of recovery.
• Truly accepting yourself— are you just telling yourself
"I'm a good person," or do you nnean it?
• Crystal and HIV— how do these two connpletely dif-
ferent phenomena so intimately interact? How does

each one affect the other? What you should know
about crystal if you have HIV or want to stay HIV-
negative.
• What do you do when someone you know has a prob-
lem with crystal?

—
WHAT IF YOU SLIP?

DOES IT MEAN FAILURE?
OST PEOPLE WHO
ly give in to temptation and use

M eventually
crystal again.
"slip,"
A slip
try to stop using crystal
meaning they eventual-
can be anything from
accepting a single bump offered by a friend to having an entire weekend
binge. The danger is that even a little slip can turn into a full relapse.
What doesit mean when you let your guard down and, after weeks,
months, or years of working on staying clean, you use crystal again?
Before answering this question, it is important to remember that crystal
addiction is a chronic relapsing and remitting medical illness. In everyday
English, this means that it is a lifelong medical illness that can be treated
but not cured. With treatment it gets better, though there will likely
be periods when it worsens again. Similar common medical illnesses
include high blood pressure and diabetes. Examining all three illnesses
addiction, high blood pressure, and diabetes —there is a remarkable
similarity in the statistics of the three, most notably the rate of treatment
adherence — actually sticking to the treatment recommendations; the

percentage of people who improve, and the percentage who experience
flare-ups in each of the different illnesses. The difficulty of sticking to
treatment for diabetes and hypertension, as well as the high rate of flare-
ups, suggests a high probability, that most meth addicts will slip at some
time during their recovery.
In the past, people thought of staying clean versus slipping as equiva-
lent to being cured or failing. However, according to the medical model,
a slip is not failure. Few would call a diabetic whose blood sugar reading
was high a failure, and while the person with diabetes, as well as friends
and family, would be disappointed, the emotional reaction would not be

as extreme as it is with a flare-up in drug addiction. Nonetheless, the
profound disappointment in a slip is still a common response, and it cre-
ates a problematic effect, common enough that in addiction it has a spe-

cific label: the ''abstinence violation effect." The expectation to stay clean
"forever and always" — as opposed to the 'just take each day as it comes"
approach — creates a significant stress that can build up self-expectations
to unrealistically high levels. If pressure is too intense, when a relapse
occurs, the profound feeling of disappointment and the sense of hopeless-

ness cause many people to give up. "I'm a failure at sobriety, so there is no
point in trying anymore." There is a double danger to the abstinence viola-
tion effect: the motivated side of the crystal user that fights for sobriety
loses hope, and the addicted side uses this as the perfect rationalization to
keep using drugs and to forget about recovery. The addict in you now has
free rein, since it has fooled the healthier part of you to surrender.
Take away the expectation that you will neiêr slip. Lose the notion that
a slip means failure. This does not mean you shouldn't hope that you will
never slip. But getting rid of unrealistic expectations may alleviate much
of the psychological pressure that can destroy your morale. Consider a
twelve-year-old boy who dreams of becoming a basketball star. He loves to
play on the courts every day after school. But if he expected to be perfect
from the beginning and accepted no room for improvement, then after the
first or second missed shot at the basket, he would give up, throw away his
basketball, and never return to the court. But even this twelve-year-old-boy
has more sense than to have such unrealistic and unforgiving expectations.
To this kid who holds on to his dream of being a famous basketball player,
missing the shot is disappointing, but it makes him want to practice even
harder. High hopes are not the same as impossible expectations. Just focus
on staying clean and sober in the present moment while you hold on to the
goal of a completely sober life.

WHAT IF YOU SLIP? I 263
Accepting the possibility that you may slip does not mean that if you
slip, you should keep using, because this is how the illness is supposed
to be. The boy on the basketball court knows he will miss a lot of shots,
but he never stops trying to make the next basket. In the medical model,
a diabetic whose blood sugar has been rising wouldn't use this as a reason
to gorge on more candy and toss away her insulin. Both the boy and the
diabetic woman see their "slips" as signs that they need to work harder to
improve. If you slip with crystal, or any other drug, it is appropriate to feel
disappointed, but don't use it as an excuse to destroy your recovery. Move
on and focus on how to get better.
If you have a therapist, a drug counselor, or a crystal relapse prevention

group, work with them and use your experience as a learning opportunity.
Examine what happened Were there subtle signs that

that led to the slip.
this was approaching? Had you been under more stress and how were you
coping with it? Had you been spending more time in places or with people
that were risky? Had you been keeping up with "the program," meaning
going to CMA meetings, seeing your therapist, calling your sponsor, and
so on? Had you been monitoring your stress level? How well were you
managing it?
If you slip but don't try to learn from the experience, the likelihood of it
happening again increases. Drug use may occur more frequently, and soon
you may find yourself completely relapsing. On the other hand, if you use
each slip as a learning opportunity, these setbacks can actually be steps that
continue to lead you forward in your path to recovery. While slips are an
expected part of addiction, if you continue to work hard at addressing them,
they should gradually decrease in frequency and become easier to avoid.
YOU ARE WHO YOU ARE,
AND THAT'S OKAY:
Acceptance— the Cornerstone of Staying Clean
God grant me the serenity to accept the things I cannot change; the
courage to change the things I can; and the wisdom to know the
difference.
—from The Serenity Prayer
ACCEPTANCE IS THE cornerstone of recov-

ery. There are countless situations in
which this acceptance appHes, though in each situation it may be called

something different, such as "surrendering," 'letting go," "admitting,"
"accepting," "coming clean," and so on. In one form or another, they all
boil down to acceptance, which is a powerful phenomenon.

In almost all religions, philosophies, and schools of thought, one of the
ultimate goals is to bring peace and happiness, almost universally attained
through some form of acceptance. Christianity teaches its believers to have
faith in God and to accept his plan for his people. Buddhism teaches that
suffering stems from ignorance and worldly desires, therefore knowledge,
mindfulness, and acceptance of what you have will end suffering. The origi-
nal teachings of Taoism espouse a natural order to the universe —harmony

is achieved when people allow the world to be as it is, that is, to accept their
place in the universe and the natural flow of events. In the West, cognitive
psychologists reframe automatic thoughts that people have in situations
that make them uncomfortable, finding ways to look at them that are more
YOU ARE WHO YOU ARE, AND THAT'S OKAY I 265
acceptable. Psychoanalysts believe that "anxiety/' a psychoanalytic term

that encompasses most negative emotional states, results when a person's
desire (the id) conflicts with what the person feels is morally "good (the '
superego). Psychoanalysis tries to help a person achieve inner peace by

reducing this conflict and teaching the "self" (the ego) to find some way
of self- acceptance.
It is remarkable that, from all parts of the world and from any point in
history, almost every religion, philosophy, and psychological theory came to

the same conclusion: acceptance, in some form, is fundamental to inner
peace.
ACCEPTANCE THE TWELVE-STEP WAY

Step One of the Twelve Steps in CMA is to admit you are powerless
over crystal. Most addicts believe that they are in good control of their use.
Drug use at its core is an attempt to be in control. In particular, drug users
try to control their emotions — for recreation or for relief of discomfort.
"Feeling sad? I can cheer up with crystal. Going to a party where I'll be
shy? I can feel social with crystal. The day feel boring? I can spice it up with
crystal. Gradually you learn that if you keep using meth, as well as other
drugs, you can control your feelings, which seems so much easier than
tackling real-world problems that make you unhappy. Eventually you forget
how to tolerate unpleasant feelings and to focus on fixing real problems,

and troubles either continue or get worse.
What feels like an easy solution —using drugs—eventually gives you the
narcissistic belief that you can handle almost anything — that is, as long as
you have your drugs. And after so much experience fine-tuning your mood
with drugs, it seems as if nobody else could possibly have as sophisticated
an understanding of your mind and your brain as you. In time, it becomes

almost impossible to hear anyone else's words as helpful.
As your illusion of control grows, the more crystal is actually gaining
control over you. The drug you were using to manipulate your feelings is
now manipulating you. In addition to signaling your primitive brain to use

more of it, it has convinced you to ignore the rational part of your brain
that would stop your drug use and try to approach problems without it. In
addition, if you are a daily user, it has made you physically dependent, so
you can't stop using it without feeling terrible. Though you had thought
you were in control, meth now has you shackled in chains.
Accepting the fact that you are addicted to cr}^stal and that you do not
have control over it is one of the hardest admissions for an addict, because
it contradicts the laws that govern this illusionary universe you live in. But
acceptance is the starting point for recovery. Without it, as long as you don't
wholeheartedly believe that crystal is controlling you, then nothing else in
treatment will make any sense.
Accepting that one is 'powerless" over crystal, and ''surrendering"
control, are extremely difficult, but once you accomplish these acts and
sincerely believe them, you can feel surprisingly liberated. Keeping up the
illusion that you are the "All-Powerful Controller," while the rational part
of you watches your life fall apart from crystal, takes a lot of work. Letting
go of the lie can actually be a tremendous relief.
ACCEPTANCE AND DEALING WITH FEELINGS

Once you have accepted that you can't control all of your feelings, now
you have to learn to tolerate them. As I mentioned on page 52, there is
an AA saying "Hold your belly," which refers to an addict's tendency to

complain ("Stop your bellyaching!") and to want a problem fixed imme-
diately. It reminds people that they can get through unpleasant situations
and encourages them to try to sit with the emotion and address problems
without reaching for drugs. Feeling uncomfortable, angry, or sad will not
kill you, though drugs may.
Not everything in life is pleasant, and not everything can be transformed
into something wonderful. You may not be good at ever\^thing you do or
get every job that you want for yourself. This is the real world, with both
good and bad things. Adjust your expectations, accepting the reality that
if some things don't turn out exactly as you had hoped, the world will not
fall apart, and in most cases, you will be just fine. The world is supposed to
be imperfect. If you understand and acknowledge the truth, rather than
hide from it, you will be much better equipped to deal with it. With more
realistic expectations, your disappointments will be fewer and easier to
tolerate. Then coping with problems will be even easier and you may feel
less compulsion to use drugs to hide from it.

— —
YOU ARE WHO YOU ARE, AND THAT'S OKAY I 26?
WABI-SABI—MAKIHG AN ART OUT OF NOT BEING PERFECT

In Japan there is an aesthetic called wabi-sabi, which developed from
Zen Buddhism. It emphasizes an appreciation of the imperfection of all
things in the world. People have tried various ways to translate the term
impermanence, transience, humility, asymmetry, imperfection —but none
quite catch the essence. Wabi-sabi embraces the fact that nothing in
nature is perfect, and this aspect of the natural world is not only accepted,
it is revered. Japanese Zen Buddhism has even turned this into an art, priz-
ing things that are imbalanced, rusted, or in some way reveal the decaying
changes of time. The fleeting existence of things — all a flower, a person s
youth, or life itself —makes them more precious. Therefore, it is all right
that they are imperfect or that they will die because this is the natural way
of the universe. If you can see your own imperfections as nature's wish,
if you are able to accept not getting the job that you tried so hard to get,
if you are able to accept that you may someday die — if you can let go of
trying to control everything and making everything perfect, then the ups
and downs of life come and go much more easily. With acceptance of the
real world and more realistic expectations, you can live a happier life with
more satisfaction.
ACCEPTANCE AND SAYING GOOD-BYE

The psychiatrist Elisabeth Kubler-Ross described the stages
of mourning as denial, anger, bargaining, depression, and acceptance.
Remarkably, these are the same feelings that crystal addicts have when
starting sobriety Whether it is mourning the loss of a person or a drug,
such as meth, these feelings are natural they are supposed to happen. In
recovery, it is expected that you will have these feelings — don't try to erase
them by going back to crystal. Just like mourning the death of a loved one,
it is important to experience these emotions in order to reach the final
stage of acceptance that crystal is no longer a part of your life, and you
will be able to feel peace.
CRYSTAL AND HIV:
How Do They Affect Each Other?
CRYSTAL AND HIV are intimately related, and

they affect each other in countless ways:
increasing your risk of getting HIV, treating the unhappiness of having HIV,
worsening an HIV-positive person's general health, possibly making HIV even
stronger, and injuring or destroying brain cells, especially when in combina-
tion. Much of this chapter refers to gay men or uses them in case examples
because this is a group in which sex and crystal are often done together, and
the prevalence of HIV is higher in this population. However, recent studies
are beginning to show similar sexual patterns emerging among heterosexual
people, so be aware that the potential risks of crystal and HIV are the same for
all users, gay or straight, male or female.
As previously discussed, crystal stimulates neurological pathways that
dramatically increase sexual desire and sexual activity, often with disregard
for protecting oneself from STDs. This is even more frequently seen in
communities that regularly use crystal in sexualized settings, such as gay

circuit parties, sex clubs, and Internet sex sites. Although some recent
statistics show that the rate of new HIV infections has finally leveled off
CRYSTAL AND HIV I 269
in the general population, the rate of new HIV infections continues to rise
among the gay men, despite the fact that many, if not most, of these newly
infected people already knew how to protect themselves.
Doctors working in the gay community have seen a frightening associa-
tion between crystal use and HIV. The medical director of Callen-Lorde
Community Health Center, for lesbian, gay, bisexual, and transgendered
people in New York City, estimates that in 2004 approximately one-third of
the clinic s patients who tested positive for HIV admitted that crystal was
somehow related to their becoming infected. Other New York City physi-
cians in private offices report similar statistics.
A joint study conducted by the University of California at San Francisco
(UCSF) and the Centers for Disease Control (CDC) showed that of the
gay men who reported using crystal meth between 2000 and 2001, 6.3
percent had been recently infected with HIV, compared to 2.3 percent
of those who did not report using crystal. In other words, crystal almost
tripled the chances of contracting HIV among these men. A study by Dr.
Steven Shoptaw, an addiction specialist at UCLA, found that 61 percent
of people seeking treatment for meth addiction at a particular clinic in
California were also found to have HIV. Both in community experiences

and in epidemiologic analyses, the medical community sees a strong con-
nection between crystal and HIV.
WHY DOES CRYSTAL MAKE SEX SO MUCH MORE APPEALING?

What is it about crystal that makes it so closely linked to HIV? Not only
does it lower sexual inhibitions that prevent people from acting on their
natural sexual urges, but for many people, it also drives the compulsion to
have sex so intensely that concern for their health and protecting them-
selves from STDs, especially HIV, gets tossed out the window. Because
sex and crystal stimulate the same brain-reward pathway, the compulsive
drive to use crystal, against all logical sense, can also create a seemingly
unstoppable drive to have sex.
Below is one man's description of his experiences of sex on crystal:
Sex on crystal is amazing. There's nothing else like it. I feel like an
animal on the hunt, and I'm determined to get my prey. I feel sexy
and attractive, and the normal shy me is not really thinking about
whether I'm going to be rejected —Fm so focused on getting my next

fuck. And it s easier to find sex because I'm so horny that I could fuck
almost anyone, even someone I normally wouldn't think was attrac-
tive. When a trick comes over and I open the door, I almost don't
even care what he looks like. He's just a piece of meat that I know I'm
going to get to fuck. Before Viagra, crystal made me a total bottom
because I couldn't get hard. I was okay with that because I could still
get fucked for hours, and it was amazing. It was like I had this bot-
tomless pit, this hunger to get fucked more. But once I started using
Viagra with crystal, getting hard wasn't such a problem and I could
top again—and fucking someone's ass, like I was attacking it, was so
amazing, could do I hours — it for the feeling was so intense. Then
when I'd finish with one person, I'd still be horny, so I'd move on to
the next guy and continue my hunt [in a sex club or online].
In addition to sexual desire, other aspects of sex on crystal increase the
risk of HIV transmission. Long periods of continuous rubbing against the

lining of the anus, rectum, vagina, and mouth cause injury and damage
to the mucosa (extremely delicate skin) lining these areas. Crystal also
dries out the mucosa, making it even easier to damage from friction. Sex
on meth is often physically aggressive, so penetration can be rough and
forceful, causing even more cuts, tears, and abrasions. Any small break
in the mucosa is an open door for HIV to enter the body and cause a new
infection, and all of the conditions mentioned above increase the risk
that HIV can infect someone by opening more doors for the virus to pass
through. The risk of becoming infected with HIV is also higher for the
person penetrating the partner, or the "top," because hours of continuous
rubbing of the penis against anything-hdnd, anus, vagina, and so on — will
create small cuts and abrasions on the surface. Without a condom to shield
them, those small cuts are also entryways for HIV into your body
As described by the crystal user above, the drive to have sex can be so
overwhelming that it causes many people to disregard their usual precau-
tions, because sex is their number one priority. The mind-blowing sex on
meth feels so important, and even urgent, that everything else seems trivial:
users ignore the need to rest, drink, or eat, let alone take the extra effort to
use a condom. Many users already know the risks of HIV, but when they
are having sex on crystal, any interference with sexual pleasure, such as
CRYSTAL AND HIV I 2?!
decreased sensation with a condom, feels intolerable.

Crystal has been so clearly linked to the spread of HIV and other sexu-
ally transmitted diseases that a joint study by UCSF and the CDC clearly
stated in its conclusion that to successfully contain the epidemic of HIV,

methamphetamine use must be reduced,
IF YOU ALREADY HAVE HIV, HOW CAN CRYSTAL AFFECT YOU?

People who already have HIV aren't concerned about getting it.
However, there are still many ways that crystal can harm them, specifically
with regard to their HIV infection. A significant issue is crystal's effect
on the immune system in general, as well as its ability to fight the HIV
that is already in the body. In studies of HIV-positive people, crystal use
was associated with an increase in the amount of HIV in the blood and a
decrease in CD4 cells (commonly called "T-cells, " or specifically ''helper
T-cells, " a type of white blood cell that is essential to the body's ability to
fight infections). The reasons for these effects are not clear. Meth may
affect HIV itself, it may affect the immune system, or it may affect people's
ability to stick to their regimen of HIV medications.

Numerous studies have consistently shown that when people are high
on crystal, they are much more likely to miss taking their HIV medica-
tions. Depending on which medications are prescribed, people must stick
closely to their regimen — at least 95 to 98 percent of the time — to keep

HIV under control and to prevent it from becoming resistant to the medi-
cations. The difficulty in sticking to medication regimens is likely the most
significant cause of worsening HIV levels and immune function in meth
users who have HIV.
HIV living in cell cultures have shown that
\n vitro (test tube) studies of
methamphetamine accelerates HIV replication five to fifteen times faster
than the replication of HIV not exposed to the drug. Because viruses and
cells in test tubes do not always act the way they would in the complex
environment of living bodies, it is important to see how methamphetamine
affects the virus in living animals (in vivo). Feline immunodeficiency virus
(FIV) is a cat virus that behaves similarly to HIV but affects cats, and it
is similar enough to HIV that it is frequently used as a model for how

HIV might behave in the human body. Just as in the test tubes studies,
the virus in FIV-positive cats given methamphetamine multiplied much
more rapidly than in cats not given any drug. It likely has a similar effect
in the human body Both test tube and animal studies consistently show
that crystal increasesHIV replication. The implication is that the same
is true for humans. One human study clearly showed that levels of HIV
increased when people used crystal; however, those people also stopped
taking their medications, so it is not possible to conclude that cr\^stal itself
increased HIV production..
CRYSTAL AND THE BODY'S IMMUNE SYSTEM

The scientific community known that amphetamine, a
has long
weaker cousin of methamphetamine, impairs immune function, consis-
tently demonstrated in both in vitro and in vivo studies. Further recent
research specifically with methamphetamine has shown similar results,
disrupting immune function in several ways.
An extremely significant effect of crystal is that it lowers the number
of CDS cells that circulate throughout the body. CDS cells, a subtype of
immune cell known as "killer T-cells," respond to chemical signals from

CD4 cells ("helper T-cells") by multiplying and forming a strong army
to attack invading infections. Killer T-cells are the first line of defense
when a person is exposed to HIV. The strength of the immune system's
initial response to the virus has a crucial impact on how the person being
infected with HIV will fare in the future. Some scientists theorize that
the stronger the initial CD8 response, the more effectively the body fights
the initial HIV infection. The less overwhelmed the body is by the first
infection, more of the immune system is presented to fight infections and

maintain good health for a longer period down the road.
Some scientists postulate that the strength of the CDS response to the
body's first exposure to HIV significantly affects the viral "set point" for
that individual —the level where the virus temporarily remains after the
initial infection. The lower the viral set point, the longer the time before
HIV breaks from its quiet state, multiplying faster and faster and wreak-
ing havoc. The less overwhelming the first attack by HIV, the better the
immune system seems to be able to keep the virus in check. A strong initial
CDS response to the body's first exposure to HIV may result in a lower
set point, and a longer period of good health. A weak CDS response may
have a higher viral set point, and HIV may progress to AIDS more quickly.
Using crystal when one is infected with HIV may result in serious health
consequences down the line.
Methamphetamine also interferes with B lymphocyte function. B cells,
a different type of immune cell, produce antibodies, one of the immune

system's strongest weapons against viruses, bacteria, and other invading
microorganisms. Methamphetamine blocks B-cells from responding to
chemical signals that orchestrate an organized response against an infec-
tion. Normally, B cells respond to the correct signal by multiplying and
producing antibodies to kill a foreign microorganism, but in the presence
of meth, the B cell response is significantly lower..
Crystal disrupts the function of the immune system in many other ways,
as well. For example, it is also associated with lower levels of chemicals
that immune cells use to communicate with each other, such as interleu-
kin-2 and gamma-interferon. It is also associated with an increase in tumor
necrosis factor (TNF), a chemical that has been found to accelerate the
progression of HIV. All of these derangements significantly prevent the
immune system from functioning properly.
If you have HIV, you should optimize your immune function. Clearly,
crystal does the exact opposite.
CRYSTAL, HIV, AND THE BRAIN

Previously I discussed in detail how crystal damages brain cells.
Similarly, HIV is toxic to the brain. The combination of the two can result
in even greater brain damage.
To review briefly, crystal damages or destroys cells in the thalamus
(affecting numerous functions ranging from attentiveness to the percep-
tion of pain) and the basal ganglia (involved with movement, motivation,
learning, and impulse control).
HIV affects similar parts of the brain, in particular the basal ganglia,
as well as many other deep-brain structures located beneath the cerebral

cortex. The proteins on the outer coating of the virus, especially Tat and
gpI20 proteins, are particularly toxic. These proteins indirectly affect
neurons by destroying astrocytes, the supportive cells that protect, nour-
ish, and assist the function of brain cells. Without astrocytes, many brain
cells cannot function properly and many of them die. Similar to crystal,
HIV significantly affects the basal ganglia, as well as other subcortical

regions. The pattern of brain damage caused by both HIV and crystal
is called ''subcortical dementia," meaning that they damage deep-brain
structures, unlike Alzheimer s disease, which affects the superficial cortex.
Subcortical dementia is characterized by slow mental processing, impaired
decision making, and difficulty performing complex mental tasks.
In animal studies using cats with FIV, as well as monkeys with simian
immunodeficiency virus (SIV —thought to be the direct ancestor of HIV),
methamphetamine caused a significant increase in viral replication, and \
this increase was even greater in the brain than in other areas of the body. \
In humans, the level of HIV in the brain can be as much as ten times
greater than the level measured in the rest of the body. Therefore, people
taking HIV medications who have ''undetectable ' levels of HIV in the
blood may still have a significant amount of virus in the brain, and crystal
use can make the HIV already there multiply even faster.
William F. Maragos and colleagues at the University of Kentucky con- ^
ducted an experiment exposing one group of animals to crystal, another

group to the Tat protein of HIV, and a third group to both crystal and Tat.
Animals exposed to crystal showed an 8 percent reduction of dopamine
function in the striatum. Those exposed to Tat protein showed a 7 percent ;
'
reduction in dopamine function. Animals exposed to both ciystal and Tat

had a surprising 65 percent decrease in dopamine function. Brain function ,
was measured one week after exposure to crystal and Tat, showing that
these were effects that persisted after crystal exposure. Another animal |
study by Chapman and colleagues showed that brain damage in mice was
notable even three weeks after exposure to meth.
The lesson here is that crystal and HIV each cause brain damage, and,
in combination, the toxicity is extremely high and persists even after the
drug is stopped.
CRYSTAL AND HIV MEDICATIONS

Crystal, like any other chemical that is put into the body, can interact
with many medications, including those for HIV. Among the HIV meds,
protease inhibitors are particularly dangerous to combine with meth, as are
many other recreational drugs because they slow the ability of the liver to
break down other chemicals, drugs, and medications. A notoriously potent
protease inhibitor is ritonovir (Norvir). Its slowing effect has been used to
boost the blood levels of other medications to make them more effective.
However, it can also allow drugs and medications to accumulate to toxic
levels that can be deadly. At least one published case report attributed a
death to the mixture of HIV medications and crystal. In this person, an

extremely high level of meth was measured in the blood that would have
been difficult to achieve by normal crystal use.
There are other non-HIV medications that can also inhibit the break-
down of crystal, including several psychiatric medications for depression

and anxiety; cimetidine (Tagamet) for indigestion and peptic ulcer disease;
quinidine, a heart medication; ketoconazole, an antifungus medication;
and many others.
Crystal can have other dangerous interactions with medications. For

example, in patients taking a certain kind of antidepressant called mono-
amine oxidase inhibitors (MAOIs), crystal can cause extreme high blood
pressure that can lead to a stroke. Just as you should always ask your doctor
if it is safe to combine over-the-counter cold medicine with your prescrip-
tion medications, you need to find out if crystal is safe in combination,
as well.
An important consideration: if your HIV medications are life saving

and you find out that your medications are not safe with crystal, what is
your reaction? If you even consider the possibility of stopping the life-
saving medications so that you can take crystal, is that a strong enough
indication of how much power crystal has over you? Why would you be
willing to trade your life for a brief high?
CRYSTAL, HIV, AND OTHER PARTS OF THE BODY

Crystal affects almost every part of the body outside of the brain. It
increases body temperature and can result in muscle breakdown, which in
its severe form is called rhabdomyolysis. This is even more likely to hap-
pen when someone uses crystal on the dance floor, where he or she is con-
tinuously active and overheated, does not rest, and is dehydrated. These
conditions increase the risk of rhabdomyolysis, which can potentially turn
into an uncontrollable cascade of muscle breakdown. The muscle byprod-
ucts of rhabdomyolysis are toxic to the kidneys, and if they overwhelm the
kidneys too quickly, kidney damage could turn into kidney failure.
Like all stimulants, crystal increases heart rate and blood pressure. Both
of these changes make the heart work harder, trying to pump an adequate
supply of blood to the entire body, including the blood vessels that nour-
ish the heart itself. When the heart works harder, it requires more oxygen,
which is carried in the blood that it pumps. For people with certain heart
diseases, such as coronary artery disease (clogged arteries in the heart),
crystal is particularly dangerous because there is already a problem deliver-
ing enough blood to their hearts under normal circumstances. Increasing
the heart s need for more blood increases the likelihood of a heart attack.
People with HIV who are taking an HIV cocktail (highly active anti-
retroviral treatment, or HAART) also are at risk for heart problems
because these medications, especially the protease inhibitors, can cause
astronomical increases in cholesterol and triglyceride levels. These are
associated with clogged arteries, heart attacks, and strokes. For people
taking HAART, there is a 5 percent cumulative annual risk of having
some heart-related illness. This means that each year you continue to
take your HAART regimen, there is an additional 5 percent risk of heart

disease. Over five years, that is a 25 percent increase in risk. HAART is
life saving and has changed the way that HIV is seen today. However, its
price is potential toxicity — in this example to the heart —and people taking
HAART still need to be careful about their health.
Heart disease caused by HIV medications may never be recognized until
an actual heart attack or stroke occurs. Therefore, if you are taking HAART,
you may not even realize that you have some heart disease. For you, using
crystal is particularly risky. This is not just a theory —unfortunately, there
have been several cases of young HIV-positive men who had heart attacks
while using crystal. There are likely many cases of small heart attacks that
are never reported or documented. Most meth users are younger than the
elderly people that we associate with heart attacks, so some meth users
who experience mild chest pain may not even consider the possibility
that they are having a heart attack —they may let it pass without giving it
a second thought. Some of my crystal-addicted patients have experienced

chest pains and did consider the possibility that they were having heart
attacks, but they did not go to the ER because they feared others would
learn that they used the drug. Their addiction was so strong that keeping
their crystal use a secret was more important than protecting their life.
Fortunately, they did not die. But they could have.

WHAT DO YOU DO
IF SOMEONE YOU KNOW
HAS A PROBLEM WITH CRYSTAL?
THIS CHAPTER IS for people who know some-

one who is addicted to crystal: a friend, a
family member, a partner, a spouse, a coworker, or anyone else in your life
who you think is hooked on meth. You may be worried, sad, frustrated with,
or even exasperated by this person and the addict he or she has become.
The prospect of dealing with someone so controlled by a drug may seem
impossible because his or her behavior is so stubborn and resistant to change.
Meanwhile, you are left feeling powerless to help as you watch the addiction
destroy your loved one. Each person who has an addiction is different and
should be approached according to his or her unique situation. This chapter
is intended to be a general guide to help you structure your own approach,
to provide a basic framework to your plan so that you can feel that there is a
logical rationale to whatever your do. Keep in mind that there are many ways
of dealing effectively with addicts, and this chapter discusses only some of the
many possible strategies to consider.
Before thinking about what to say to an addict, it is important to under-

stand what he or she is experiencing as thoroughly as you can without
actually using the drug yourself. Read the chapters in parts 1 and 2 to
learn as much as you can about crystal —what it is, how it works, and how
it makes people feel, both the good and the bad. Also read the chapters
that define addiction and see if this reflects what you see in the person
who concerns you.
Armed with that knowledge, if you see true addiction, this chapter may
offer you some useful guidance on how to deal with the addicted person
in your life.
ADDICTED FRIENDS OR FAMILY MEMBERS
If you are dealing with addiction in someone particularly close to you,

the thought of confronting that person can be daunting because you may
be afraid of pushing him or her away At the same time, if you do noth-
ing while the addiction continues, you are much more likely to lose that
person from your life, and worse yet, he or she could even die as a result
of the drug. If the addict issomeone you care about, stepping in to help
is one of the best things you can do, even if it means being rejected.
To lay the groundwork, I hope you have read the other chapters mentioned
above and understand that both biological and psychological processes are
dictating the behavior of your loved one. He or she did not become addicted
because he or she is stupid, weak, or bad. Something pleasurable or psycho-
logically helpful about crystal enticed the person to start using crystal, and
that helpful quality, together with its strong neurophysiological basis, keeps
this person continuing use it, despite all of the obvious problems that you
see it has caused. Try to find out what those positive things, are so that you
can understand why it is so difficult to quit meth.
Think back to what your loved one was like before crystal and look
at what you see now. If there is a dramatic difference, you can see the
power of meth on the human mind and body. The person that you knew
before crystal took hold is still in there somewhere. However, many of the
behaviors and moods you see — lying, hiding, withdrawing, moodiness,
irritability, paranoia, rageful outbursts, depression, and so on — are a result
of crystal highs, crashes, and cravings. Most of these behaviors are resolved
when addicts become sober, though addiction also causes some changes
in character that are difficult to change back.
a
WHAT DO YOU DO IF SOMEONE YOU KNOW HAS A PROBLEM WITH CRYSTAL? I 279
Recognizing the behaviors and moods caused by crystal addiction is
essential to give you clearer vision when you observe them. When you
confront your loved one, if you meet angry resistance, you can better see
what behaviors and words are symptoms of the addiction, which may
help you not to take angry words too personally. If a friend broke his leg,
would you expect him to accompany you on a mountain hike? Of course
not. You consider his limitations based on what he has to work with —
bum leg. Similarly, addicts are working with a chemically altered mood, a
physiologically based compulsion to continue using, and a neurologically

impaired ability to make judgments. As with the friend with the broken leg,
you cannot expect the person to react in the most rational way when told to
quit. If you make your expectation more realistic, you can be less emotion-
ally vulnerable if your loved one responds to your goodwill with anger and
denial. You may feel less of the bite of angry personal attacks against you,
and this may allow you to feel more compassion than frustration.
How to Discuss the Problem
There are several ways to tell a loved one that you are concerned about
his or her crystal use: a private one-on-one conversation, a group discus-
sion with other friends or family members, or the traditional intervention.
There is no one single right way to do it. You may need to experiment with
different tactics. I usually prefer to test the waters with a one-on-one
talk because it is less intense and confrontational. The response can give
you an idea of how receptive or resistant the person is. If a one-on-one

conversation accomplishes little, at least it has given you some informa-
tion about how much resistance you are working against. This will help
you decide how much intensity you need for the next step — bringing in a
crucial and influential person, having a group conversation, or cranking up

the heat to a group confrontation or all theway up to a fully orchestrated
intervention in which family and friends make prepared statements and
the discussion is facilitated by an experienced leader. For an intervention,
a predetermined rehabilitation program is often arranged so that if the
person agrees to treatment for his or her addiction, the process can start
immediately, before he or she has a change of heart.

When to Have the Talk
Choosing the right time to talk can have a significant impact on how
receptive your loved one is to your words. When addicts are high on crystal
or any other substance, this is obviously not the right time. If they have not
used crystal for several weeks, they may be in a more rational state. However,
they may also be feeling so well because the pain of the crash has waned
and denial is easy. Because they feel all right at the moment, they can easily
rationalize their behavior. Consider talking to them during a crash. They may
be feeling tired, depressed, anxious, or generally miserable. At that particular
moment they may actually welcome an offer for help because they feel so
distressed and vulnerable. Take advantage of the times when they are so
aware of the bad effects of crystal that they are impossible to deny. On the j
other hand, they may be feeling so tired and irritable that they crave more ^
cr\^stal to help themselves feel better. Being so focused on that, they will not
be at all receptive to outsiders' comments. Perhaps the best time to talk is
soon after the crash,when they feel better enough to have a conversation,
but have the recent memory of an unpleasant crash still very fresh in their
minds. During that particular period, addicts may be the most motivated to
stop using drugs. Because motivation and insight change constantly, be on
the lookout for a good window of opportunity.
Before you have your talk, be prepared. Make a list of all the things you
want to cover and how you are going to say them, choosing wording that
is honest about your feelings but nonjudgmental. You know the situation
will be uncomfortable for both of you, and strong emotional reactions can
throw you off guard. A defensive person may try to engage you in circular,
illogical arguments, and you will quickly find yourself derailed from your
original plan. Keep yourself close to your framework and use a mental
script (or a written script —write it as if it were a letter, and it won't sound
so unnatural if you have to read your own words) that will allow you to
emotionally step back and stay focused on your point.
What to Discuss
Start the conversation with positive comments, for example, "I love you
ver)' much," or "You are one of the most important people in my life, and
our friendship means so much to me." Use your first comment to establish
a supportive tone for the rest of the conversation. If you begin with criti-
cism or even a sympathetic comment with negative overtones, such as "I'm

worried about you," the conversation has already become confrontational,
and your loved one will immediately take a defensive position, shutting
his or her ears to whatever discussion follows. A positive statement at the
beginning reminds both of you why you are having this talk —because this
person matters dearly to you, and vice versa. Hopefully a loving and sup-
portive start will soften up the person's defensive reactions a little, and if
he or she becomes hostile and combative, think of your first statement to

remind yourself that you are having this conversation because you care,
not because you are angry and want to cause someone else emotional pain.
Keep reminding yourself about this point so that you can step back and try
not to become engaged in heated, emotional arguments.

Identif)^ recent behaviors that you have seen or that are factually indis-
putable. For example, your friend did not show up to meet you for dinner;
she has been missing days of work every week; he has admitted to having
unprotected sex and has contracted several sexually transmitted diseases.
The more specific you can be, the less room you leave for argument or
denial.
Frame these behaviors as concerns that you have for someone you
very much care for, not as accusations. Monitor your language and tone
of voice —speak slowly, and keep your volume low and the pitch of your
voice from getting higher and tighter. This will prevent you from sounding
critical or attacking and will reduce the likelihood of a defensive reaction.
Remain calm and caring.
Remind your loved one about his or her own goals and desires in life:
friends, family, career, education, or whatever else he or she considers

important. Use these as the measuring sticks for explaining how well
or badly the addict has been doing while under the influence of crystal.
Avoid describing any problems in terms of your own hopes or disappoint-

ments; otherwise, the person will only become more convinced that you
do not understand or care at all. Your loved one will try to believe, and try
to convince you, that you are only interested in yourself. Resist the urge
to feel guilty or to question your own motives. You already know that you
are trying to show your loved one his or her own problems, not yours.
Have list of recommendations prepared — possibilities include working
with a drug counselor; checking out local twelve-step meetings; joining

a non-twelve-step support group about addiction; reading a book, such
as this one, to learn more about crystal; or going to rehab. Do not leave a
discussion about problems without any possible solutions, otherwise it will
truly feel like criticism and can leave the person feeling hopeless.
Your addicted friend or family member may not immediately accept
your message that there is a problem. He or she may still be in too much
denial or may be feeling so defensive that it may take a little time alone
to digest your comments. At the very least, having the conversation shows
the person that you are available as a caring support around the issue of
crystal addiction, and that if he or she ever wants to address the addiction,
there are specific ways to get help.
Do Not Get Emotional
Confronting loved ones about their addictions is extremely difficult,
but being on the receiving end of a confrontation is even harder. Expect

that your friend or relative will be defensive, even angry, and more than
likely he or she will argue and try to oppose everything you say. The per-
son may retaliate by trying to provoke the same angry or hurt feelings in
you. Remind yourself that this is part of the addiction, and if you start
feeling anger well up, stop talking, take a deep breath, and go back to the
discussion framework that you prepared. If you let yourself become angry,
the discussion changes from a rational discussion to an emotional battle.

Then you give the person good reason not to listen to you, and the natural
reaction in a fight is to push against anything thrown out by the opponent.
Instead, remain calm and compassionate.
What to Expect
Friends and relatives have all sorts of reactions to "the talk. ' Some may
be able to listen and feel grateful for your support. Unfortunately, most
people are not so receptive. Despite your best efforts to keep the discus-
sion from turning into an argument, you will usually encounter some
defensiveness and denial. However, that does not mean that the person
did not hear you. If you see a severe problem, more than likely he or she
sees it, too. Even when the person is able to admit to some of the points
you bring up, do not expect to end your discussion in total agreement.
Knowing that complete agreement is not the goal will help you to back off
at the right time and not feel so frustrated. When you end the discussion,
accept that there may still be disagreement between you, mentally step
back, let the person know that you are still there for support, and leave the
person to think about the things you have discussed. The conversation may
take place several times in a variety of ways. But keep giving a consistent
message: you care about this person, he or she has a problem, and you
think he or she can get better.
After the Talk, What Else?
Now that you have voiced your concern, follow though with what you
said. Do not disappear, but remain present as a support. If the person
decides to take the plunge and quit meth, he or she will be going through
an arduous period of physical, emotional, and mental changes. Your loved
one may need your help now, more than ever, to get through the depres-
sion, moodiness, and agonizing cravings of quitting.
Spend time together and show how important it is to you that this per-
son is trying to clean up, and engage in activities that do not involve drugs
or alcohol.Remind each other what your interpersonal bond is really about
and enjoy each other's company in a meaningful way. You are literally com-
peting with crystal, which may have become your loved one's new "best
friend." But the friendships are different —one is chemical, compulsive,
destructive, and out of control, while your is deep, meaningful, emotional,
and supportive. You hope that at some point the person will see this.
When you spend time together, do not constantly focus on drugs, always
monitoring the other person's behavior and asking what he or she has been
doing. The person may feel overly scrutinized, self-conscious, or embar-
rassed, especially right after being confronted. Allow a little breathing
room after your discussion. But if you detect new problems or a downward
^
h spiral into the old, have another talk.
,
; Above all else, if you yourself do drugs, do not use crystal or other drugs
t in front of the person you are trying to help. How can he or she take you
seriously if you are not able to stop using drugs? Model healthy, drug-free
behavior and demonstrate that you can enjoy yourselves without drugs.
Also, keep in mind that the even the sight of anything associated with
"
drugs can trigger physiological reactions in the brain that cause intense
craving. Why would you put this person through that agony? Using drugs
in front of recovering addicts is disrespectful of their efforts to stay clean,
and it is downright cruel. Would you insist that a friend with severe asthma
visit your grandmother and her twenty cats? Don't do things that will
increase your loved one's risk of relapsing, and give him or her great respect
for working so hard at sobriety.
If your friend or family member has been successful at staying away

from drugs, give positive reinforcement and acknowledge that he or she
is doing a great job, but do not be patronizing. Overcoming crystal addic-
tion is truly a tremendous feat. Do not underestimate the difficulty, and
consider yourself lucky if you never have to face such a challenge. Mean
it when you say, *'Wow, it's been three weeks without any crystal and you're
doing great!
Setting Limits
If your loved one is not able to stop using crystal, set some limits as to
what you A buddy who never shows up, lies, or asks for money
will tolerate.
and never pays back can become an annoyance. A sister who constantly
it
calls up for support because she fears she caught another STD after
another story of unprotected sex on crystal can become tiresome, if not

exhausting. You may start to feel annoyance, resentment, and even dread
building up whenever you hear the person's voice, knowing that regard-
less of your warnings about crystal and risky sexual behavior, nothing ever
changes. Your reaction is a sign that you are burning out. Set some limits
to protect yourself and your relationship.

On the other hand, instead of feeling irritated by such behaviors, some
people feel the opposite —concerned and overprotective. This can be
problematic if it leads you to ignore dangerous warning signs, cover up for
your loved one when he or she misses appointments or work, or help to

pay rent or other bills because money is always spent on crystal instead.
This t}npe of behavior is called "enabling." You may do it out of love and
concern, but in the end, it allows the addict to continue using drugs even
longer because he or she never has to face the difficult consequences. If
you stop making excuses for your loved one, he or she may get into trouble
at work or even get fired. Without your financial assistance, he or she may
get evicted and become homeless. As horrible as it sounds to let this hap-
pen to someone you care about, it may take just such a dramatic loss to
break the illusion that crystal creates — that everything will be all right, as
long as there is more crystal.
Think about what your limits are. What can you tolerate, and which of
your behaviors may be enabling? Carefully decide what you believe is help-
ful support versus what will fuel the addiction. Expect that your loved one
will try to put a lot of emotional pressure on you and make you feel guilty
for bailing him or her out of trouble. Being prepared with your limits will
let you withstand the emotional pressure and help you to feel confident
that the help you give — or refuse to give — is for a good reason. For example,
you may offer to be available to your friend at any time, day or night, for
emotional support; however, you will not lend any money, and you will not
participate in any activities with this person that may involve drugs.
After you decide what your limits are, explain them to your loved one
making the terms as explicit and concrete as possible, with no room for
misinterpretation, loopholes, or excuses. Some examples of clearly defined

limits are: "I will not lend you any money," or "We will not engage in any
activities where drugs may be around, and if drugs are there, I will leave."
Addicts, especially when they are desperate, can be excellent lawyers,

relentlessly arguing almost any case. "But you said that if I needed money
for food . . "This time is different — I'm sick and I need to go to the doc-
tor." Make your limits so clear that there is no question. You are never the
only option for an addict. Even in worst-case scenarios, there is almost
always another option: for the sick, there is the emergency room; for the
homeless, there are shelters. Sometimes it takes extremes such as these
to make addicts understand how much their lives have changed because
of crystal.
Whatever limits you set for yourself, stick to them. Be gentle and caring,
but be firm. If your addicted son tries to manipulate you with guilt, find
other ways to help without overstepping your limits. If your addicted friend
is sick but has no insurance and can't afford medical care, take her to the
free city clinic or offer to help take her to the nearest Medicaid office, where
she can apply for help herself. These are not glamorous options, but this is
exactly what your loved one needs to see. Addicts needs to face up to just
how ugly things have really become. Only then will they realize that they
need to change.
Do not exceed your limits, thinking, 'Just this once, when he really needs
my help." Doing so may actually worsen the situation. Consider the clas-
sic behavioral science experiment with mice. Mice can be trained to hit a
lever by pairing it with a reward, such as receiving a pellet of food. If they
receive food after hitting the lever five times, they continue to hit the lever
in order to get more food. If food pellets are no longer delivered, the mouse
keeps trying, but after numerous unsuccessful attempts, the mouse eventu-
ally gives up and forgets about the lever. The behavior is 'extinguished." If,
however, instead of completely stopping the food supply, you allow some food
pellets to fall at random times when the lever is pushed, the mouse will con-
tinue pushing the lever. This is called "intermittent positive reinforcement."
Randomly giving the food pellet actually makes the mouse continue to push
the lever even more tenaciously than if you wêre giving it at a predictable
rate. The mouse does not know when the food will come, but he knows that
if he diligently keeps pushing the lever, food will eventually come.
The exact same phenomenon occurs in humans. If you set a limit but
on rare, "extreme" occasions, you ignore your restrictions "because it was
a special situation," the addict then learns that, if he or she is persistent
enough, you will eventually cave in and do what he or she wants. Then
the limits become meaningless. Rather than understand your limits as
an important part of recovery, the addict will focus on how to get you to
exceed your limits again.
What Happens If the Person Relapses?
Once someone decides to stop crystal, no matter how well he or she

does in recovery, relapse is always a possibility. In fact, it is likely that it will
eventually happen. If someone starting out in recovery starts using crystal
again, do not despair or lose hope. Remember that addiction is a chronic
relapsing and remitting disease, meaning that once people have it, they
have it forever — there will be stable periods, but there may also be flare-
ups. When a woman with hypertension has been able to control her blood
pressure for years, but her blood pressure spikes, is she a failure? No it's —
the nature of the illness. She needs to tr}^ to get it back under control and
change or intensify her treatment.. For friends and family, this model is
helpful because it provides more realistic expectations and helps decrease

frustration and burnout.
WHAT DO YOU DO IF SOMEONE YOU KNOW HAS A PROBLEM WITH CRYSTAL? I 28?
In crystal addiction, some relapses are expected, and a few fallbacks,

some might argue, may be help to show how 'powerless" the addict is,
despite the most sincere desire and efforts to stop. Instead of feeling
frustration and despair, tr)^ to help the addict use the initial relapses as
learning opportunities.
Get Support
You should not go through the experience of dealing with an addicted

family member or friend alone. Some resources of support include Al-Anon
meetings (support groups specifically for friends and family of addicts)
and psychotherapists experienced with addiction issues. Do not isolate
yourself. Talk to people about what you are going through. Al-Anon can
be particularly helpful because it offers peer support from other people
in situations similar to yours, and it teaches proper limit setting and how
to recognize unintentional enabling behavior. At Al-Anon meetings, you
can check in with others when you are feeling uncertain or doubtful about
whether you are being too strict or too lax, and you can reinvigorate your
motivation when you feel emotionally depleted. Most important, Al-Anon
helps you accept the fact that there is only so much that you can do. You
can test your limits by sharing them in the meetings, and you will feel more
comfortable with what you do —and what you refuse to do — in order to
help the addicted person.
When to Pull Back
When is enough enough? If violence or abuse is ever involved, pull

out. Your own safety comes first. If you find that you cannot stick to limits
that you set, or if your friend or relative continues to push you, manipulate
you, or treat you badly, and all attempts to change this have failed, then
your relationship with this person may have turned completely toxic. If
continuing your present relationship has not been productive but instead
it has been destructive to you personally and to the relationship itself,
then it may be time to pull back. Pulling back does not mean giving up on
the addict, though he or she may experience it as such. It means putting
an end to a way of interacting that is harmful to both of you. If you have
questions about whether you have reached this point, ask other people in
your support network, especially other people who have been in the same
situation as you, or discuss your situation with an addiction specialist.
If you decide to pull away, you are not deserting your loved one. To make
this clear, explain exactly what you are doing: 'Tm sorry, but I can't spend
time with you anymore. It seems like no matter what we plan, you keep
disappearing because you're getting high, or it seems like you're always
asking me for money. Nothing has really changed, and I won't go on hke
this. You are my friend (or brother/whatever), and I am here for you if you
want to get better from this addiction. But I've tried everything I can to
help you, and nothing has worked. So you need to change in order to be
in my life again."
It sounds strong, and it feels harsh, but sometimes it must be done. A

45-year-old woman told be about her struggles with her twenty-two-year-
old son, who was a crystal addict. The mother and son truly loved each
other. However, the son's addiction was so strong that no matter what
limits the mother put on his interactions with him, her son found ways ^
to get around them. When she invited her son over for dinner, she later
discovered he had stolen some of her expensive possessions to sell for
crystal. Once her son took her car without permission. Despite the love
that the mother and son felt for each other, the addiction was so strong
that the son betrayed his mother repeatedly to feed his need for crystal. As
difficult as it was, the woman had to sever ties with her son. She realized
that unless she stopped enabling him, he would never find his way out of
his addiction. Losing this precious relationship was one of the major nega-
tive consequences that the addicted son needed to experience. Eventually,
he came to see that crystal cost him more than money — it almost cost
him one of the most important people in his life. Two years later the son
decided to go to rehab. Now he is working seriously on recovery and he
has reestablished contact with his mother.
ADDICTED PARTNERS, SPOUSES, AND SIGNIFICANT OTHERS

If THE CRYSTAL addict in your life is not just a friend or relative but is your
partner (life companion, spouse, boyfriend or girlfriend, domestic part-
ner, or however you describe the person with whom you share your life),
everything mentioned above applies, though your situation could be much

more complicated. If you live together, you are much more emotionally
interdependent, and you may be financially intertwined with joint bank
accounts and property. For all these reasons and more, your behavior and
emotional reactions have a greater impact on each other.
Is your partner lying to you, using up the money in your joint account,
stealing from you, or cheating on you? If you have a sexually open rela-
tionship, is your partner having more sex outside the relationship? Is your
partner having unprotected sex with others and potentially exposing you to
STDs? Is your partner getting high and forcing you to have sex when you
don't want to or in ways that are so aggressive that you don't enjoy it?
With all these questions running through your mind, do you feel you
can trust this person with whom you share everything? You may feel angry,
frustrated, or cheated. If your partner really cared about you, how could
he or she act with such blatant disregard for you? And if you cannot trust
your partner, why should you even stay together as a couple? These are
some of the heart-wrenching questions that partners of crystal addicts
struggle with.
To make sense of this confusing situation, keep in mind that some of
the behavior you are seeing is likely the addiction rather than the person
you used to know and love. Ask yourself if your partner was like this before
using crystal. Try to distinguish the difficulties in your relationship from
the symptoms of crystal addiction. If some of the behavior is clearly due
to drug use, withdrawal, or uncontrollable craving, then the enemy may
be the addiction, though it seems as if it's your partner. In that case, try to
address the addiction before packing your bags and calling it quits.
Have "the talk " described at the beginning of this chapter. When dis-
cussing what your partner's goals are in life, include your joint goals as a
loving team. Remind your partner of what the two of you used to dream of
having together. And remind your partner that crystal is ruining not just his
or her life, but also the life that the two of you have built together.
Protect Yourself
While you are trying to be compassionate and caring toward your partner,
always be sure to take care of yourself. This is not being selfish. If you are not
healthy or safe, you cannot help your partner. And if you are finding that your
relationship is destructive to you, then in the long run it is hurtful to your part-
ner, as well. Some things to keep in mind:
If there is ever any violence or abuse, leave immediately.

If your partner is using up all of your joint savings, then divide
the money fairly into separate bank accounts and get rid of any
joint credit cards. If you are financially dependent on him or her,
you need to find a way to protect yourself financially or you may

find yourself homeless because of your partners addiction.
If your partner is having sex outside the relationship, always use
condoms when the two of you have sex.
Get checked regularly by your doctor for sexually transmitted
diseases.
Get emotional support from friends, family, support groups, a
therapist, or Al-Anon.
Set limits for yourself and your partner. What are you able to tolerate?
What limits are healthy for the relationship? What limits do you need to
address the crystal addiction? When you draw the line, be compassion-
ate but firm. If necessary, seek the assistance of a couples' therapist who
specializes in addiction.
In the end, the relationship may not survive, at least not in its present
state, while your partner is heavily addicted. Losing a partner to crystal is
painful, but hitting that rock bottom may eventually motivate that person
to change and get help.
On the other hand, your relationship may survive. It will be different,
and it may become even stronger than before as the two of you learn how
to navigate the treacherous seas together. This requires communicating
well, learning new ways to support each other, and understanding each
other's needs more clearly. These are all assets that make any relationship
stronger and deeper.
APPENDIX 1
Abstinence-Based Treatnnent
and General Information Resources
The following resources are facilities and Web sites that provide infor-
mation and/or treatment for crystal addiction based on an abstinence-

based model. Except for the twelve-step organizations, this list comprises
programs that specifically have experience in working with methamphet-
amine addiction. There are many other excellent programs that offer gen-
eral addiction treatment. This list does not guarantee the quality of the
treatment of each facihty or the accuracy of information presented in the
Web sites. Therefore, use your own discretion and judgment when inves-
tigating these resources. When possible, some information is provided
describing details of what these programs offer.
NATIONAL: Al-Anon Family Group Headquarters, Inc.
Al-Anon/Alateen (Canada)
Provides information and locations of Ai- 9 Antares Drive, Suite 245
Anon and Alateen meetings in the United Ottawa. ON K2E 7V5
States. Canada, and Puerto Rico. Phone: (613) 723-8484 Fax: (613) 723-0151
Al-Anon Family Group Headquarters. Inc. Al-Anon General Outreach
1600 Corporate Landing Parkway (888) 4AL-AN0N or (888) 425-2666
Virginia Beach, VA 23454-5617

Phone: (757) 563-1600 Fax: (757) 563-1655 Alateen (Al-Anon meetings specifically for
teens with an addicted family member)

www.al-anon.alateen.org/meetings/
meeting.html
Alcoholics Anonymous United States Health and Human Services,
AA World Services. Inc. Substance Abuse and Mental Health
P.O. Box 459 Service Administration (SAMHSA)

New York, NY 10163 1 Choke Cherry Road
(212) 870-3400 Rockville, MD 20850
www.alcoholics-anonymous.org Center for Substance Abuse Prevention
(CSAP) (240)276-2420
Crystal Meth Anonymous (CMA) Center for Substance Abuse Treatment
CMA General Services Chair (CSAT) (240) 276-1660
8205 Santa Monica Boulevard PMB 1-1 U www.samhsa.gov/index.aspx
West Hollywood, CA 90046-5977
(213) 488-4455 (Hotline)
www.crystalmeth.org CALIFORNIA:
AIDS Project LA (APLA) Crystal Metham-
A Key to Methamphetamine-Retated Lit- phetamine Program
erature (Web site information resource) The David Geffen Center
An exhaustive, frequently updated list of 61 1 South Kingsley Drive
literature on various aspects of meth- Los Angeles. CA 90005
amphetamine published by the New (213) 201-1600
York State Department of Health. AIDS www.apla.org/prevention/crystal_meth.html
Institute.
www.nyhealth.gov/diseases/aids/harm_re- Crystal Meth Treatment (Laguna Beach)
duction/crystalmeth/docs/meth_litera- Treatment program for both gay and straight
ture_index.pdf people with crystal-specific treatment
(800) 930-METH
KnowCrystal.org www.crystalmethtreatment.com
Provides general information about crystal
in a nonjudgmental way. This site does Friends La Brea
not offer treatment services. Los Angeles
www.KnowCrystal.org 1 134 N La Brea Avenue

West Hollywood. CA 90038
National Institute of Drug Abuse (323)463-7001
Neuroscience Center Building
6001 Executive Boulevard
Rockville, MD 20852
www.nida.nih.gov
APPENDIX 1 I 293
S.T.O.P. (Stimulant Treatment Outpatient NEW YORK:

Program) Callen-Lorde Community Health Center
3180 18th Street, Suite 202 326 West 18th Street
San Francisco. CA 94102 New York. NY 10011
(415) 502-5777 (212)271-7200
www.callen-lorde.org
San Francisco Lesbian/Gay/Bisexual/Trans-
gender Community Center Center for Motivation and Change
1800 Market Street 276 Fifth Avenue. Suite 1101
San Francisco. CA 94102 New York. NY 10001
(415) 865-5555 (212) 683-3339
www.motivationandchange.com
Van Ness Recovery House
Los Angeles Columbia University Medical Center De-
(323) 463-4266 partment of Psychiatry
(Frequently conducts studies that offer free
treatment, including medication and
FLORIDA: therapy, for methamphetamine users with
Gay and Lesbian Community Center of HIV. At the time this book is going to press.
South Florida Columbia has a study offering treatment
1 71 7 N Andrews Avenue of methamphetamine addiction with
Ft. Lauderdale. FL 33311 modafinil combined with therapy.)
Phone (954) 463-9005 Fax (954) 764-6522 1051 Riverside Drive
www.glccsf.org New York, NY 10032
Contact persons: Dr. Judith Rabkin (212)
543-5762 and Dr Martin McElhiney (2121
MASSACHUSETTS: 543-5331
Fenway Community Health Center
7 Haviland Street The Crystal Clear Program at the Addiction
Boston. MA 021 15 Institute of New York (formerly known as

(888) 242-0900 the Smithers Treatment Institute)
1111 Amsterdam Avenue

New York, NY 10025
(212) 523-6491
Gay Mens Health Crisis (GMHC) Life Beyond Meth
120 W 20th Street Behavioral Health Services
New York, NY 10011 St. Vincent's Hospital
General: (212) 807-6655 203 West 12th Street, 3rd Floor
Hotline: (800) 243-7692 New York, NY 10011
Substance Use Counseling and Education Phone: (212) 604-8220
infornnation line: (212) 367-1354 www.lifebeyondmeth.com
www.gnnhc.org/progranns/suce.htnnl
The Lesbian. Gay, Bisexual & Transgender WASHINGTO, D.C.:
Comnnunity Center Whitman-Walker Clinic
208 West 13th Street 1407 S Street. NW

New York. NY 10011 Washington. DC 20009
Phone: (212) 620-7310 (202) 797-3500
Fax: (21 2) 924-2657 http://wwc.org/
www.gaycenterorg
APPENDIX 2
Harm-Reduction Resources
The following resources are facilities and Web sites that provide infor-
mation and/or treatment for crystal addiction based on a harm-reduction

approach. Some of the facilities are also listed in Appendix 1 (abstinence-
based treatment) because they offer both models of care. This list does
not guarantee the quality of the treatment of each facility or the accuracy
of the information provided by the individual Web sites. Use your own
discretion and judgment when investigating these resources.
ATLANTA: LOS ANGELES:

Atlanta Harm Reduction Center AIDS Project Los Angeles (APLA)
(404) 526-9222 (213) 201.1600
www.atlantaharmreduction.org www.apla.org
NEW YORK:
BOSTON: The Lesbian, Gay. Bisexual & Transgender
Fenway Community Health Center Community Center

(617) 267-0900 212-620-7310
www. f e n way h e a It h 0 rg
. www.gaycenterorg
CHICAGO: Gay Mens Health Crisis (GMHC)
The Chicago Recovery Alliance General Hotline: (800) 243-7692

www.anypositivechange.org Substance Use Counseling and Edu-
cation (S.U.C.E.) information line:
(212) 367-1354
www.gmhc.org/programs/suce.html
Positive Health Project S.T.O.P. (Stimulant Treatment Outpatient
301 West 37th Street. 2nd Floor Program)
New York. NY 10018 (415)502-5777
(212)465-8304. x33
tevans San Francisco Lesbian/Gay/Bisexual/Trans-
Exclusive drop-in hours for gay and bisexual gender Community Center
men with concerns about crystal (415)865-5555
Fridays 5:00-8:00 p.nn. vwvw.glccsf.org
SALT LAKE CITY: WASHINGTON, D.C.:
Harm Reduction Project Whitman-Walker Clinic
(801)355-0234 (202) 797-3500
www.harmredux.org http://wwc.org
SAN FRANCISCO: GENERAL INFORMATION WEB SITES

The Stonewall Project www. tweaker org
(415) 502-1999 www.harmreduction.org
www.dancesafe.org
Haight-Ashbury Free Clinics www.clubdrugcounselorcom
(415) 565-1908 www.canadianharmreduction.com
www.hafci.org www. k n owe rysta 1. 0 rg
www.knowmoremeth.com
GLOSSARY
abstinence: Completely stopping the use of a substance. This is in con-

trast to "moderation management/' which is a philosophy that drug or
alcohol use can be continued in a controlled and moderate way.
acamprosate: A medication that is used for alcoholism, thought to de-
crease the urge to drink by enhancing GABA transmission and de-
creasing overactive gluatamate activity at NMDA receptors. A recent
large-scale study questioned whether acamprosate has actual benefit
for alcoholics, finding its effect similar to a placebo. It is under inves-
tigation for use in other chemical addictions.
acute: Sudden onset. E.g., "acute pain" occurs suddenly, as opposed to
"chronic pain," which is long lasting. An acute event, which starts sud-
denly, can become chronic if it continues for a long time
ADD: See attention-deficit/hyperactivity disorder
ADHD: See attention-deficit/hyperactivity disorder
amygdala: A part of the brain where emotional memory is stored.
anabolic steroids: A class of drugs that mimic testosterone and are used
to treat hormone deficiencies, low libido, severe weight loss from HIV
and cancer, and anemia. They are also misused by health people to
promote muscle growth.

astrocyte: A type of cell in the brain that supports other brain cells that
are responsible for thinking, feeling, and other basic "brain functions,"
by protecting, nourishing, and assisting their function
attention deficit disorder: See attention-deficit/hyperactivity disorder
298 I GLOSSARY
attention-deficit/hyperactivity disorder: A psychiatric illness in which

a person has difficulty with a number of mental functions, most notably
focusing attention on uninteresting material and having difficulty filtering
out surrounding distractions, having difficulty suppressing movements or
words and needing to move about constantly There are three subtypes:
1) primarily inattentive; 2) primarily hyperactive; and 3) combined inat-
tentive and hyperactive. In adults, it is more common to see the primarily
inattentive subtype, also commonly known as attention deficit disorder or
ADD. Children are more commonly seen with the combined type. This
condition is usually called by its simpler acronym ADHD. Note that there
are many other conditions that can cause difficulty with concentration,
such as depression, anxiety, drug effects, medication side effects, fatigue,
and many others.
basal ganglia: A part of the brain with many functions, including move-
ment, as well as relaying brain signals between the body and the rest
of the brain. Commonly known illnesses such as Parkinson's disease

and Huntington's disease originate here. Cells in the basal ganglia use
dopamine as their primary means of communicating with other parts
of the brain and body.

behavioral therapy: A type of psychotherapy that works on the assump-
tion that physical and emotional reactions occur when one thing or
event is paired with another. For example, the pairing of a computer
with the event of smoking crystal causes the body and mind to have a
reaction when seeing a computer, which then reminds the mind and
body of feelings associated with smoking crystal. Behavior therapy
works to extinguish the reaction by repeatedly exposing a person to
one of the two things without the other until the associated reaction
stops. In this example, exposing a person to a computer until the feel-
ings about smoking crystal disappear, allowing a person to work at a
computer safely without having overwhelming cravings to use drugs.

benzodiazepines: A class of medications that target the GABA receptors
in the brain to decrease anxiety and to promote sleep. Benzodiaze-
pines are habit-forming, meaning that after taking benzodiazepines for
several weeks, the body becomes accustomed to their effect, and after
they are stopped, sleep and anxiety worsen. In some cases, withdrawal
can be severe, including extremely uncomfortable physical symptoms
and possibly seizure.
GLOSSARY I 299
booty bumping: Nickname for a method of using crystal by dissolving

it in a small amount of liquid and squirting it into the rectum. Booty
bumping is often done to enhance the experience of anal sex.

bottom: Nickname for a person who is the receptive partner in anal sex.
This role occurs commonly in gay sex when a crystal user is not able
to achieve an erection because of crystal but still wants to have sexual
intercourse.
brain-reward circuit: A pathway in the brain that is highly associated
with pleasure, compulsive repetition of behavior, and addiction. The
more a drug stimulates this circuit, the more addictive it tends to be.
The brain-reward circuit uses dopamine to function.
bullet: Nickname for a small bullet-shaped device used to discreetly
dose and use small, measured doses of powdered drugs, such as crys-
tal, cocaine, and ketamine.
bump: Nickname for a small amount of crystal or other powdered drug
(cocaine, special K, etc.) that is snorted. A bump can be snorted from
the tip of a small object, such as a a key, or from a snorting device
nicknamed a "bullet."
Campral: Brand name for acamprosate.
carbohydrates: A class of foods made of small to large chains of sugar.
This includes table sugar, fructose from fruits, potatoes, pasta, and
rice.
carbs: Nickname for carbohydrates.
CD4 cells: A type of immune cell, a subgroup of T lymphocytes, also

known as T-cells, that is responsible for signaling other immune cells
to attack foreign invaders, such as viruses and bacteria. CD4 cells are
also the target of HIV, which disables the central organizer of the im-
mune system. In this way, HIV cripples the entire immune system.
CD<4 count: A measure of the number of CD4 cells in a sample of blood,
which is used as a measure of the health status of the immune system
in people with HIV.
CDS Cells: A type of immune cell, a subgroup of T lymphocytes, also known
as T-cells that attack foreign invaders such as bacteria, parasites, and virus-
es. They are called into action by signals from CD4 cells, which stimulate
them to multiply and attack the foreign invaders.
cerebral cortex: The outer wrinkled surface of the brain, which is where
most of logical thinking and judgment are performed.
500 I GLOSSARY
chronic: A chronic illness is a condition that has persisted for several
months to years. This is in contrast to an "acute illness," which occurs

suddenly and is usually brief, though an illness with an acute onset can
become chronic if it continues and becomes a long-standing illness.
cingulum: A specific part of the brain that has been associated with mo-
tivation and initiating behavior.
circuit parties: Large dance parties with thousands of gay men held in
cities throughout the world, where gay men travel from long distances
to celebrate. These parties started as ways for closeted gay men to
escape their homophobic communities and join an accepting group

where homosexuality was not condemned. The association with a par-
ty gave the feeling of celebrating their sexual orientation. Drug use be-
came extremely prevalent at these parties, where many gay men used
this venue to "escape" the painful reality of living in a homophobic
society. The understanding that social dictums such as the "evil" of
homosexuality were not necessarily correct likely allowed gay men to
challenge mainstream prohibitions against many drugs.

clean: A term used by the addiction community meaning "not using drugs
or alcohol." It is possible to be "clean" but not "sober." See sober.
club drugs: Drugs commonly used at raves and circuit parties, usually
referring to Ecstasy, ketamine, methamphetamine, and GHB.

cognitive therapy: A t)ê of psychotherapy that focuses on correcting
incorrect thoughts that lead to unwanted emotions or behaviors.
conning out: The act of telling someone that you are gay or bisexual. This
includes "coming out to yourself," meaning admitting to yourself that
you are gay or bisexual. This term comes from the expression "coming
out of the closet," meaning coming out of hiding about your sexuality.
compulsion: A strong urge to do an action that creates intense and pos-
sibly intolerable anxiety until the action is done. E.g., the compulsion
to use a drug, even after several months of not using the drug.
counselor: The general term for a person who works with you to assist you
in achieving a particular goal. A counselor can be from almost any disci-
pline —drug counselors, social workers, psychologists, and psychiatrists.

However, in certain states, people can call themselves "counselors" with-
out any licensing or regulation of the quality of their work. Find out the
background and training of any counselor you work with.
GLOSSARY I 301
crash: The period after using a drug, which is usually unpleasant, like a
"car crash."
creatinine phosphokinase: A substance that is in muscles, which is
released when there is muscle damage. Creatinine phosphokinase is
toxic to the kidneys, and in large amounts can cause kidney failure.
cybersex: The activity of deriving sexual pleasure while communicating with

another person over the Internet. Usually this involves masturbation and
use of the Internet to achieve an orgasm, but this is not always necessary
to gratify the sexual needs. Cybersex has also begun to refer to any Internet
activity, such as viewing pictures or videos to achieve orgasm.
delirium tremens: A specific medical condition that can occur from
alcohol withdrawal that includes severe confusion, disorientation, agi-
tation, and hallucinations. This is a serious medical condition that is
potentially fatal.
destigmatize: To take away the negative feelings that society has closely
associated with something. E.g., destigmatizing addiction is important
to allow addicted people to stop feeling shame and to be more willing
to admit their problem and seek treatment.
detoxification (Detoxing): The process of stopping a drug (including
alcohol) and allowing the body to adjust to functioning without the
drug in the body.
Diagnostic and Statistical Manual, Fourth Edition: A manual published

by the American Psychiatric Association that describes specific criteria
for psychiatric illnesses.
dopamine: A chemical used by cells in the body to send signals to other
cells that cause changes in body function. E.g., dopamine affects sig-
nals directing heart function, mood, movement, pleasure, concentra-

tion, and motivation.
dopamine transporter: A protein in the cell wall of brain cells that
transports dopamine from the space outside brain cells back into the
brain cell, where it can be packaged into vesicles for use again. The do-
pamine transporter is blocked by both cocaine and methamphetamine,
allowing dopamine to accumulate and causing the high of the drugs.
dope-sick: The feelings of withdrawal when stopping an opiate, such as
heroin, Vicodin, or OxyContin.
DSM-IV: See "Diagnostic and Statistical Manual, Fourth Edition."
502 I GLOSSARY
dysthymia: A low-level depressed mood that persists most days of the

year for several years.
Ecstasy: See methylenedioxymethamphetamine.
electrolytes: Atomic particles such as sodium, potassium, and calcium
that are important for the proper functioning of cells in the entire body.
Imbalances in electrolytes can have a significant effect on brain, heart,
and kidney function.
free radicals: Chemically reactive particles that cause derangement of
cellular DNA, damage cell function, and destroy cells in the body. Free
radicals have been implicated in causing cancer, brain damage from
drugs, and aging.
frontal cortex: The front part of the brain's surface, which is involved in
higher-level thinking, such as logic, judgment, and decision making
gamma hydroxybutyrate: A drug usually ingested as a liquid, which
suppresses brain activity, causing lowering of inhibitions, euphoria,
increase in libido, and sedation. Known commonly as GHB, it is ex-
tremely dangerous because the amount to cause unconsciousness is
only slightly higher than the amount required to cause the high. In
overdose, or when combined with other brain-supressing drugs, such
as alcohol, benzodiazepines, ketamine, and opiates, it can be fatal.
GHB: See gamma hydroxybutyrate

glutamate: A small particle called a neuropeptide that is used to send
signals between cells throughout the brain. Glutamate is especially
known for its use in the cerebral cortex, where logical thinking and
judgments are processed.
HAART: See highly active antiretroviral treatment.
hallucinations: Perception of something that is not actually there. There
can be hallucinations of any of the senses: visual (sight), auditory (sounds
and voices), tactile (feeling things on the skin, such as crawling bugs), ol-
factory (smells), and gustatory (taste). People may be aware or unaware of

the fact that hallucinations are not actually there.
harm reduction: A philosophy of addiction treatment that identifies and
works towards the goals of the addict, rather than forcing the addict to
take on goals assigned by the clinician. Harm reduction emphasizes self-
motivation, self-reliance, and self-empowerment. It relies on the assump-

tion that people can make logical choices about what to do if they are given
GLOSSARY I 503
enough information and education. This model works best in the early stag-
es of crystal use, before neurological changes occur that disrupt the ability
to make logical decisions regarding drug use.

helper T-cells: A specific type of immune cell, also known as CD4 cells,
that recognize a foreign invader (e.g., bacteria, viruses, and parasites),
and sends signals to other immune cells to activate them to multiply
and destroy the foreign invaders. Helper T-cells are also the primary
targets for HIV, which therefore destroys the immune system s ability
to fight infections.
highly active antiretroviral treatment (HAART): A regimen of three

or more medications that must be taken simultaneously to fight HIV,
sometime referred to as an "HIV cocktail."
hypothalamus: A small area of the brain that secretes hormones, regu-
lates body functions such as eating and sex, and controls the "body
clock," telling your body when to sleep and awaken.
immune system: The system of cells and chemicals secreted by these
cells that kill foreign invaders, such as bacteria, viruses, and parasites.
in vitro: A type of biological study that uses chemicals and/or cells but
does not involve animals or humans. These studies are helpful, but
animal studies are considered a better approximation of what happens
in humans. Human studies are the best at showing what actually hap-
pens in people.
in vivo: A t\ê of biological study that uses humans or other animals.

These studies are considered a better reflection of activity in the hu-
man body, with human studies being the most accurate.
inpatient rehabilitation: Intensive drug addiction treatment in a hospi-
tal setting.
insight: Clear knowledge about oneself, one's thoughts, and ones be-
havior. E.g., a person can have good insight into the fact that he is
addicted to crystal. Conversely, a person can have poor insight into his
addiction and justify his weekly use as recreational and "totally under
my control," though he has not been able to pass a weekend without
crystal in six months.
ketamine: A "club drug" that is usually in cr\^stalline white powder form,
derived from a liquid drug used for injection. Ketamine is a drug used
as a general anesthesia for surger\' on children and on animals in vet-
erinary medicine. Also called Special-K.

504 I GLOSSARY
killer T-cells: A specific type of immune cell, also known as CDS cells,
that are activated by helper T-cells (CD4 cells) to multiply and destroy
foreign invaders, such as bacteria, viruses, and parasites.
limbic system: A grouping of brain circuits that are linked and regulate
emotions.
line: A rough measure of a powdered drug that is snorted. The powder is
laid on a flat smooth surface and divided into lines of various lengths
and widths. This is a very inexact measure because the size of the line
can vary with the user, and as an addiction worsens, the size of one line
can become much larger than it had been in previous years. Therefore
the statement that "I do the same number of lines in a night as I used
to" does not necessarily mean that drug use has not increased.
lymphocyte: A type of blood cell that is part of the immune system, which
destroys foreign invaders, such as bacteria, viruses, and parasites.
major depression: See major depressive disorder.
major depressive disorder: A psychiatric illness in which a person
has low mood, together with disturbed sleep, change in appetite, de-
creased energy and motivation, poor concntration, or a decreased abil-
ity to experience pleasure. A combination of some of these symptoms

must be present for at least two weeks. This condition often responds
well to treatment with antidepressant medication and psychotherapy
It can be worsened by crystal use and is also a condition that, when
untreated, causes relapse to drug use.
Matrix Model: A model of treatment specifically tailored for people ad-
dicted to crystal.
MDMA: See methylenedioxymethamphetamine.
mesolimbic pathway: A brain pathway leading from the ventral tegmen-
tum in the brainstem to the nucleus accumbuns in the brain. The
mesolimbic pathway is associated with pleasure, as well as compulsive
repetition of behaviors that may not necessarily be pleasurable.
meth mouth: A dental condition of softened, severely decayed teeth
that results from poor nutrition and osteoporosis with weakened tooth
structure; dry mouth, which increases bacterial growth that destroys
teeth; and tooth grinding and jaw clenching caused by crystal
methylenedioxymethamphetamine (MDMA, or Ecstasy): Club drug that

works on serotonin, taken in pill form. Ecstasy usually causes people to
feel relaxed and takes away social anxieties and inhibitions.
GLOSSARY I 305
modafinil: A medication used primarily to promote wakefulness with

very little addiction potential. Modafinil has many actions, including
increasing glutamate activity in the prefrontal cortex. It has been found

to be helpful for cocaine addiction and is being investigated as a pos-
sible treatment for meth addiction. (Brand name Provigil.)
mu-opioid receptor: A subtype of receptor for opiates on cells in the
brain and throughout the body This subtype is most commonly known
for its euphoric and pain-killing effects when opiates, such as heroin
and morphine, are taken.
mushin: A Zen Buddhist concept meaning "no mind." Through mushin
one tries to achieve a higher spiritual state by emptying the mind,
which involves letting go of worries of the past and the future.
mutations and resistance: Changes that happen to the DNA (genes) in
a virus or bacteria that make it resistant to medications that are used

to effectively kill the virus or bacteria.
naltrexone: A medication that blocks opiate receptors, opposing the effect
of opiates, such as heroin and morphine. It has been helpful in treating
certain addictions, such as alcoholism and opiate dependence.
neocortex: The cerebral cortex, or outer covering of the brain in humans,
which is a new (neo) evolutionary change that is present in human
brains, when compared to the more primitive brains of other animals.
neurophysiologic: Pertaining to biological changes in nerve cells, par-

ticularly in the brain.
neurotransmitter: Chemicals used by brain cells and other nerve cells
throughout the body to communicate with other nerve cells or parts
of the body.
NMDA receptor: See N-methyl-D-aspartic acid receptor.
N-methyl-D-aspartic acid receptor: A protein in the cell wall of brain
cells that is activated by glutamate to cause a series of subsequent ac-
tions within the brain cell. It is thought to be an important receptor in
addiction, affecting cravings and the ability to make judgments neces-
sary to avoid relapse.
nonoxynol-9: A chemical developed as a spermicide that is used in lu-
bricants with condoms. Nonoxynol-9 had been found to killHIV in

test tubes, so it was recommended to use in lubricants to prevent HIV
transmission. However, it was found to cause so much irritation to
mucous membranes inside the rectum and vagina that it was thought
506 I GLOSSARY
to possibly make HIV transmission easier, so it is recommended that

people not use lubricants containing nonoxynol-9.
norepinephrine: A neurotransmitter that has a stimulating effect. It is also
called noradrenaline, which is more commonly known as adrenaline,
nucleus accumbens: An area in the brain that is associated with reward
and addiction.
paranoia: A mental state in which a person falsely believes that others
are following, watching, or in some way want to harm him.
Parkinson's disease: A neurological disorder affecting movement. The
most prominent and common symptoms are tremor (shaking), expres-
sionless face, and difficulty initiating a movement, such as walking or
standing up from a chair. It is caused by damage to dopamine neurons
in a part of the brain called the basal ganglia.
party (v. to party): A slang term meaning to use drugs, most often refer-
ring to using crystal.
PET scan: A test similar to X-rays and CAT scans that makes images
of parts of the body. PET scans of the brain show how active differ-
ent areas are during different activities, such as resting, concentrat-
ing, performing specific mental tasks, etc. PET scans are often used
to compare the brain function of a particular group compared to the
general population. E.g., PET scans can compare the brain function
of crystal users to non-crystal users.
physiological: Referring to the biological workings of the body.
placebo: An inactive pill or other sham treatment used in research with
animals and people to compare the effect of an actual treatment to a

fake treatment, to rule out nonmedication effects, such as the power
of suggestion that taking a pill will make an illness better.
PNP: Slang abbreviation for 'party and play," referring to having sex while
using crystal.
Positron emission tomography scan: See PET scan.
prefrontal cortex: A specific part of the cerebral cortex that is located in
front of the part of the brain that controls movement. The prefrontal
cortex is believed to coordinate thoughts, goals, and behavior. People
who have damage to this area of the brain have been observed to intel-
lectually know "right from wrong" but in their behavior, they act upon a
strong need for immediate gratification. Therefore, proper functioning

GLOSSARY I 507
of this area of the brain is crucial for being able to maintain sobriety.
Even if an addict intellectually knows that crystal use will destroy his
life, he needs proper functioning of the prefrontal cortex to resist the
urge for immediate gratification to use crystal again.

program, the: A slang term in Alcoholics Anonymous that refers to the
process of recovery, which involves ongoing effort. To stay sober in
recovery, one must "work the program."

protease inhibitor: A class of medications used to treat HIV. This class
of medications is very powerful at fighting HIV, but it also interacts
with many other medications and drugs. The interaction could result
in a dangerously high level of drug in the body, or certain drugs and
medications could result in a low level of protease inhibitor, which
would then allow HIV to grow and multiply.
Provigil: Brand name for modafinil.
psychodynamic psychotherapy: A type of psychotherapy based on the

principle that much of a person's behavior is motivated and controlled
by thoughts and feelings in the unconscious (i.e., thoughts and feel-
ings that are outside a persons awareness).

psychosis: a fundamental derangement of the mind (as in schizophre-
nia) characterized by defective or lost contact with reality especially as
evidenced by delusions, hallucinations, and disorganized speech and
behavior.
rationalizing: Tr\dng to make excuses for doing something that you know
is wrong. E.g., "Brian rationalized that he could do a little crystal be-
cause it had been several months since he had used any drugs, and he
was entertaining friends he hadn't seen in four years. He didn't want
to spoil the fun and thought doing a couple of bumps wouldn't be a
problem."
rave: A large gathering of teenagers and young adults, from hundreds to
thousands, where people dance to techno music. Raves are a setting in
which use of club drugs is a normal part of the culture.
recovery: A state of actively trying to remain sober and in control of an
addiction. "Alison has been an alcoholic since she was seventeen, but
she has been in recovery for the past five years.'
relapse: Falling back into drug use after achieving a period of sobriety.
relapse prevention: A type of addiction treatment with the ultimate goal
308 I GLOSSARY
of complete abstinence, using various practical techniques to avoid or

prevent relapse.
remit, remitting: To resolve or get better. Addiction and hypertension
are remitting and relapsing illnesses because they both get better with
treatment, but they can worsen at times, and this is expected as part of
the course of the illnesses.
residential rehabilitation: Similar to inpatient rehabilitation, residen-
tial rehabilitation is addiction treatment in a live-in setting, though
not in a hospital. The advantage of residential rehabilitation is that it
removes addicts from the environment full of stressors and triggers

that would increase an addict s chance of relapsing, and it allows the
addict to intensively devote full time and attention to achieving and
maintaining sobriety.
Revia: Brand name for naltrexone.
rhabdomyolysis: A medical condition in which muscles break down at
a rapid rate. This is extremely dangerous because muscle breakdown

products are toxic to the kidneys and can cause kidney failure if not
caught and treated quickly.
rock bottom: A frightening low-point in an addict's life that helps him to
realize that his drug use is a serious problem that needs to stop.
seizure: Abnormal electrical discharges in the brain that can result in
loss of consciousness and contraction of all muscles, followed by shak-

ing of all parts of the body.
selective serotonin-reuptake inhibitor: A type of medication that block
the reuptake of serotonin, allowing serotonin to accumulate around

cells in the brain. These medications are used to treat depression,
anxiety, social anxiety disorder, panic disorder, obsessive-compulsive
disorder, post-traumatic stress disorder, and many other conditions. It
is a nonaddictive treatment for these illnesses.
serotonin: A neurotransmitter known to be important in maintaining

mood, anxiety, and certain aspects of thinking and memory.
sexual orientation: Attraction to people of the same, opposite, or both
genders. This includes heterosexual, homosexual, and bisexual. Sexual
orientation is different from gender identity, which is the inner sense
of being male, female, or "other."
sexuality: A general term encompassing various aspects of a persons
GLOSSARY I 309
identity that relate to sex, including sexual orientation, gender identity,

preferred sexual activities, etc.
slam: Slang term for using a drug intravenously
sober: Not using drugs or alcohol. Sometimes the word sober also implies
actively working on fighting addiction. E.g., the expression ''Clean but not
sober ' means a person is not currently using drugs but is not "working the
program" or actively working on keeping addiction under control.
sobriety: See sober.
social anxiety disorder: A psychiatric illness in which a person has a
disabling reaction of anxiety when exposed to other people, usually
with fearful thoughts of being scrutininzed and humiliated.

social phobia: See social anxiety disorder.
Special K: See ketamine.
SSRI: See selective serotonin-reuptake inhibitor.
stimulants: A class of medications and drugs that increase energy, de-
crease the need for sleep, and usually suppress appetite. These sub-
stances act primarily on dopamine and norepinephrine.
striatum: A part of the brain in the basal ganglia that deals with reward-
linked motivation, planning, and impulse control.
subcortical dementia: A type of brain damage occurring in deeper parts
of the brain. Subcortical dementia can result from various conditions,
including high blood pressure, multiple sclerosis, HIV, and chronic use
of drugs such as crystal.
thalamus: Relays motor, sensory, and emotional signals to different parts
of the brain
therapist: A person who works with people to help them sort out prob-
lems. Therapists can be of various disciplines, such as drug counselors,
clinical social workers, psychologists, and psychiatrists. Within each
discipline, there are different styles of therapy, including cognitive
therapy, which is very "here-and-now"; psychodynamic, which focuses

on the effects of early childhood experiences on adult life; hypnothera-
py; etc. In many states, there is no strict regulation on what constitutes
a therapist; therefore, the quahty of care you may receive can var}^. If
you find a therapist with good experience who works in a style that fits
you well, he or she can be extremely helpful, especially in helping to

guide you out of the grip of addiction, because a therapist can point
310 I GLOSSARY
out things that you may know but do not allow yourself to see. For
example, when you start to rationalize and begin to fall back into drug
use.
top: A slang term among gay men, which means the "active '
person in a
sexual couple. In anal sex, the "top" penetrates the "bottom."
trick: A slang term among gay men, which means a person that you meet
for sex only Similar to a ''quickie" or a ''hookup." A trick is a casual sex
acquaintance, in contrast to a person you meet for ongoing dating.

triggers: Anything that causes a person to start wanting a drug. The ex-
pression "people, places, and things" refers to triggers to be aware of to

protect yourself from relapsing.
tweak: A slang word used as a verb meaning "to use crystal." The adjec-
tive "tweaked" means high on crystal, and a "tweaker" is a person who
uses cr\^stal.
twelve-step programs: A type of program based on the original Alcohol-

ics Anonymous (AA) model, comprising of twelve "steps" to achieving
and maintaining sobriety These programs strive for complete absti-
nence, are peer-led, and strictly adhere to anonymity Twelve-step pro-

grams use the terms "God" and "Higher Power," though there are many
people in these programs who are not Christian or religious. Some
examples of twelve-step programs are Alcoholics Anonymous (AA),
CrystalMeth Anonymous (CMA), Cocaine Anonymous (CA), Mari-
juana Anonymous (MA), Narcotics Anonymous (NA), and Overeaters
Anonymous (OA). This model of group treatment can be adapted to
most addictive and compulsive behaviors.
vagus nerve: A nerve that runs from the upper chest, through the neck,
and connects to various parts of the brain. Stimulation of this ner\ê
can cause many changes in the brain, including changes in mood, mo-
tivation, and thinking.
ventral tegmentum: A small area in the brainstem that is connected by
nerve fibers to the nucleus accumbens. These signals are mediated by
dopamine and are often associated with pleasure.
viral Load: The amount of a virus that is measured in the blood. This
term is most commonly used in reference to HYV because it is a ba-
rometer for how healthy a person with HIV is. A low or "undetectable"
viral load usually signifies that HIV infection is under good control.
GLOSSARY I 311
withdrawal: A physiological state in which the body needs more of a
drug. A body goes into withdrawal when becomes accustomed to the

it
presence of a drug. When the drug is no longer present, the body feels
sick. A crystal addict in withdrawal can feel tired, depressed, hungry,
anxious, and even suicidal. Symptoms of withdrawal vary for each par-
ticular drug.
works: A slang term for needles and syringes used to inject drugs such as
crystal, cocaine, and heroin into the bloodstream (intravenous drug use).
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i
ACKNOWLEDGMENTS
Thank JW, for being a wise role model who quietly and gently
you,
encouraged me throughout my life. am grateful to the many individuals
I
who were brave and generous enough to share their valuable experiences
and wisdom, which have tried in this book to share with others. Thank
I
you to my many colleagues and mentors, including Petros Levounis and

Marc Galanter, who helped me to persevere and galvanized me to start this
project, which I personally felt was so vital. I give my deep appreciation to
family and friends who have been their patience, encouragement, and sup-
port. And, of course, thank you, RK and AT for showing me that through
that special combination —the courage to push forward together with the
acceptance of the limitations life gives us —we can accomplish anything,
including controlling addiction and finding happiness in life.
INDEX
10-day detox schedule, 108-10 AL-Anon, 287

alcoholism., 56
A alprazolam, 103-4
aluminum, 41
AA (Alcoholics Anonymous), 139-40,
amantadine, 104
144
Ambien, 106-7
Abilify, 165
American Soceity of Addiction
abstinence, 297
Medicine, 26-27
acamprosate, 158, 297
Amish, 7
acceptance, 264-67
amphetamines, xii, 15, 105, 211, 272
acupuncture, 156, 225-26
amygdala, 297
acute, 297
anabolic steroids, 297
Adderall, 30, 105, 211
anhydrous ammonia, 40
addiction
anorectics, 66
addict terminology, 11-12
antidepressants, 164, 202, 275
biological basis, 115
antipsychotic drugs, 165
brain effects, 51
anxiety, 265
defined, 45-48
APA (American Psychiatric
developing, 66-67
Association), 45
discussing, 279-84
appetite supressants, 34
of family, friends, partners, 278-90
aripiprazole, 165
neurochemistry, 51
astrocytes, 273, 297
overcoming, 8—10
Atarax, 106
physical dependence, 53-54
Ativan, 103, 199
psychological aspects, 52
recognizing, 55-63
sexual addiction, 256-58 B
understanding, 114-16 B cells, 273
ADHD (attention-defit/hyperactivity baclofen, 159
disorder), 210-14, 298 basal ganglia, 273, 298
adrenaline, 28 behavior therapy, 196, 298
See also norepinephrine Benadryl, 106
330 I INDEX
benzedrine, xii, 16 cingulum, 300

benzo-like medications, 106-7 circuit parties, 18-19, 34-35, 65, 198,
benzodiazepines, 103, 106, 159, 199, 300
298 clean, 300
bipolar disorder, 165 clonazepam, 103
booty bumping, 20, 299 clonidine, 103
bottom, 299 club drugs, 300
bowel ischemia, 36 CMA (Crystal Meth Anonymous),
brain 141-45, 265
addiction, 51 cocaine, xii, 31
cells, 32 cognitive distortions, 195-97
development, 26 cognitive therapy, 300
effects of crystal meth, 30-32, 37-38 coming 300
out,
functioning, 49-50 compulsion, 300
HIV, 273-74
brain-reward circuit, 49-51, 299 compulsive repetition, 33
Brodie, Jonathan, 159 Concerta, 30, 105
Buddhism, 264, 267 condoms, 20-21, 94-95, 248
bullet, 299 coping skills, 132
bump, 299 counseling, 137-39
bupropion, 104 counselor, 300
BWS (Breath Water Sound), 222 CPK (creatinine phosphokinase), 36,
301
c crank, 16
crashing, 95-98, 301
caffeine, 30
cravings, 126
CAGE questionnaire, 56
crystal methamphetamine
California Department of Health
chemical structure, 29
Services, 27
defined, 28-39
Campral, 158, 299
history of, 15-27
cannabinoid receptors, 157
ingredients, 16, 40
carbamazepine, 165
manufacture of, 17, 40-42
carbohydrates, 299
safe use, 89-99
Catapres, 103
street names, 11,15
CBT (cognitive-behavioral therapy), 191
cybersex, 20, 301
CD4 cells, 271-72, 299
Cylert, 30, 105
See also T-cells
CDS cells, 272, 299
CDC D
(Centers for Disease Control),
269 date-rape drug, 24
cerebral cortex, 299 Decision Matrix, 67-84
chlorpheniramine, 106 deep breathing, 126-28
chlorpromazine, 165 delirium tremens, 301
Chlortrimeton, 106 dental decay, 34, 93, 95
Christianity, 264 Depakene, 165
chronic, 300 Depakote, 165
cimetidine, 275 depression, 163-64, 202-10
INDEX I 331
destigmatize, 301 F
detoxing, 102-10, 301
See also withdrawal
family members, 278-90
Federal Controlled Substance Act of
Dexedrine, 28, 105
1970, 16
diazepam, 103
digestive system, 36
fertilizer, 40
diphenhydramine, 106
FIV (feline immunodeficiency virus),
271-72, 274
discussing addiction, 134-37, 279-84
flumazenil, 161
doctors,108-10
Focalin, 30, 105
dopamine
and addiction, 164
free radicals, 31, 302
157, 160,
Freud, Sigmund, 200
antagonists, 159
defined, 28, 35, 301
friends, 230-46
effects of crystal meth, 30-32, 35,
addicted, 278-90
51, 104
frontal cortex, 302
schizophrenia, 39
transporters, 31, 301 G
dope-sick, 301 GABA (gamma-aminobutyric acid), 157
dry mouth, 34 GABA receptors, 104, 161
DSM-IV {The Diagnostic and Statistical gabapentin, 158
Manual of Mental Disorders), 45, Gabitril, 159
47, 301 Galanter, Marc, xi-xiii
attention-deficit/hyperactivity disor- gay men
der criteria, 212-14 drug use, 7, 11, 17-22, 65
depression criteria, 204-5 parental expectations, 174
dysthymia criteria, 206 party scene, 231-32
social phobia, 189 psychological considerations, 53
dual diagnosis, 162-65 (GVG) gamma-vinyl GABA, 159
dysthymia, 205-7, 302 Geodon, 165
See also depression GHB (gamma-hydroxybutyrate), 105,
302
E ginseng, 30
glossary, 297-311
Ecstasy, 18, 198, 302, 304
glutamate, 51, 160, 302
ego, 265
electrolytes, 302 Grant, I., 65
emergency room visits, 26 guarana, 30
employment, 208-10 gum chewing, 93
ephedra, 30
ephedrine, 30 H
ERP (exposure with response preven- HAART (highly active anti-retroviral
tion), 196-97 treatment), 275, 303
Eskalith, 165 Haldol, 165
ether, 40 hallucinations, 39, 302
euphoric recall, 79, 81 haloperidol, 165
expectations, 171-87 Halsted, William, xii
332 I INDEX
harm-reduction, 88-89, 302-3 K

resources, 295-96
35-36 Kemstro, 159
heart,
helper T-cells, 272, 303
ketamine, 18, 303
Khantzian, Edward, 243
heroin, xii, 53
kidneys, 36
heterosexual men, 27, 65
killer T-cells, 272, 304
high-risk situations, 118-21, 131
kindling effect, 39
HIV, 27, 268-76
Klonopin, 103, 199
and immune system, 101
Kubler-Ross, Elisabeth, 267
medications, 91, 161, 274-76
transmission of, 6-7, 20, 248
homosexuality. See gay men L
honeymoon period, 79 Lamictal, 165
Humphries, 142 lamotrigine, 165
hydroxazine, 106 lead, 42
hyperactivity, 213 lifestyles, 118, 130
hypothalamus, 303 limbic system, 304
line, 304
I lithium, 40, 165
Lithobid, 165
id, 265
immune loneliness, 230-46
system, 272-73, 303
lorazepam, 103-4
impulsivity, 213
loss of control, 48
in vitro, 303
lubricants, 94-95
in vivo, 303
Lunesta, 106
inattention, 213
lymphocyte, 304
ingredients of crystal methamphet-
Lyrica, 104
amine, 16, 40-42
purity of, 42
mjecting crystal, 20, 32, 92 M
inpatient programs, 149-55 ma huang, 30
inpatient rehabilitation, 303 major depression, 203-4, 207, 304
insight, 303 See also depression
insurance companies, 153 manufacture of crystal meth, 16, 40-42
internet, 119-20 purity of, 42
recipes for crystal, 41 MAOIs (monoamine oxidase inhibi-
resources, 291-96 tors), 275
sex sites, 20 Maragos, William R, 274
lOPs (intensive outpatient programs), marijuana receptors, 157
145-46 Marlatt, G. Alan, 67, 116
massage, 223-25
J Matrix Model, 148-49, 304
McKellar, 142
JCAHO (Joint Commission on
Accreditation of Healthcare
MDMA (methylenedioxymethamphet-
amine), 198, 304
Organizations), 151—52
medications, 156-62
jetlag, 50
Say No", 73, 121, 146
HIV, 274-76
"Just
INDEX I
social anxiety, 198-200 nucleus accumbens, 32, 306

withdrawal, 103-10 nutrition, 96
meditation, 227-29
melatonon receptors, 106 0
mercury, 41
obesity, 66
mesolimbic pathway, 32, 49, 304
olanzapine, 165
Metadate, 30, 105
oral sex, 95
meth labs, 41
organizations, 291-96
meth mouth, 34, 93, 95, 304
osteoporosis, 34
methamphetamine. See crystal meth-
overdose, 38-39
amphetamine
oxcarbazepine, 165
methanol, 40
methyl group, 28
methylene, 41
p
methylphenidate, 30, 105, 211 paranoia, 39, 306
Mexico, 41,42 parents, 174-76
military, 15-16 Parkinson's disease, 38, 306
modafinil, 105-6, 159-61, 305 partners, 288-90
Moos, 142 Patterson, T.L., 65
Mormons, 7 pemoline, 30, 105
morphine, xii PET (positron emission tomography)
motorcycle gangs, 16 scans, 37-38, 125, 306
mu-opiod receptor, 305 physical dependence, 53-54
muriatic acid, 40 physiological dependence, 47
muscles, 36-37 PI (protease inhibitors), 161
mushin, 305 placebo, 162, 306
mutations, 305 PNP (party and play), 20, 306
precautions using crystal meth, 92
N prefrontal cortex, 306
pregabalin, 104
NA (Narcotics Anynymous), 143
pregnancy, 24-25
naltrexone, 158, 305
primitive brain, 49-50
National Survey of Substance Abuse
the program, 307
Treatment Services, 151-52
Prometa, 161-62
natural remedies, 30, 96
protease inhibitor, 307
needles, 92
Provigil, 105-6, 159, 307
negative emotions, 128-30
pseudoephedrine, 40, 42
neocortex, 50, 305
psychiatric illnesses, 162-65
nephrons, 36
psychodynamic psychotherapy, 200-
Neurontin, 158
201, 307
neurophysiologic, 305
psychological relief, 52
neurotransmitter, 30, 305
psychology, 306
NMDA (N-methyl-D-aspartic acid),
psychosis, 39, 307
157, 305
purity of crystal meth, 42
nonoxynol-9, 94, 305-6
norepinephrine, 28, 164, 306
Norvir, 274
534 I INDEX
R sexual activity, 65, 93-95, 148, 247-57,

^
269-71
Rabkin, Judith, 161
sexual orientation, 308
ramelteon, 106
sexuality, 308
rationalizing, 307
Shoptaw, Steven, 269
raves, 19, 198, 307
shyness. See social anxiety
Reagan, Nancy, 73, 121, 146
288-90
significant others,
reasons for crystal meth use, 64-66
SIV (simian immunodeficiency virus),
recovery, 307 274
rectal crystal meth use, 20, 32
SKY {Sudarshan Kriya Yoga), 222
refusal strategies, 121-23
slamming, 20, 92, 308
Reiki, 226-27
sleep, 106-7
relapse, 261-63, 286-87, 307
Smith, Michael, 156
prevention, 113-33, 215, 307
Smith, Robert, 139-40
relaxation, 219-21
smoking crystal meth, 19, 32
relaxation exercises, 126-28
snorting crystal meth, 19, 32, 92
remitting, 307-8
SNRls (serotonin-norepinephrine
Requip, 104
reuptake inhibitors), 198-99
residential programs, 149-55
sobriety, 309
residential rehabilitation, 308 188-201, 309
social anxiety,
resistance, 305 230-46
social circles,
resources, 291-96 136-37
social support,
reuptake, 202 176-77
societal expectations,
Revia, 158, 308
solvents, 40
rewarding yourself, 124—25
Sominex, 106
rhabdomyolysis, 37, 275, 308
Sonata, 106
Risperdal, 165
Special-K, 303, 309
risperidone, 165
spouses, 288-90
Ritalin, 30, 105, 211
SSRIs (selective serotonin-reputake
ritonovir, 274
inhibitors), 198, 308
rock bottom, 308 264-67
staying clean, 113-33,
ropinirole, 104-5
stereotyped motor activity, 33
Rozerem, 106
Stewart, 142
stimulants, 28, 309
s toxicity, 38-39
safe use of crystal meth, 89-99 street names of crystal meth, 11, 15
SAMHSA (Substance Abuse stress mangement, 215-29

and Mental Health Services striatum, 37, 309
Administration), 151-52 subcortical dementia, 309
scheduling time, 123-24 substance abuse disorder, xi
schizohphrenia, 164-65 defined, 45-48

seizure, 308 Sudafed, 40
self-esteem, 169-87, 191 suicide, 165
Semple, D.J., 65 superego, 265

serotonin, 38, 164, 198, 308 superlabs, 41-42
sertraline, 164 support groups, 139-45, 287
INDEX I 335
Symmetrel, 104
syringes, 92
vagus nerve, 222, 310
Valium, 103, 199
valproate, 165
T-cells, 271-72 valproic acid, 165
See also CD4 cells ventral tegmentum, 32, 310
Tagamet, 275 Viagra, 248, 270
Taiwan, 25 viral Load, 310
talking about drugs, 134-37, 279-84 vitamin C, 96
Taoism, 264 Vivitrol, 159
Tat protein, 274 VNS (vagus nerve stimulator), 222
teenagers, 7, 25-26
Tegretol, 165 w
thalamus, 37, 273, 309
wabi-sabi, 267
therapist,309
the Wave, 128
therapy, 137-39
weight loss, 66
Thorazine, 165
Wellbutrin, 104
tiagibine, 159
Wlien Boys F/y,239
Timko, 142
Wilson, Bill, 139-40
TNF (tumor necrosis factor), 273
withdrawal, 47, 100-110, 310-11
tolerance, 47
medications, 103-10
toluene, 40
See also detoxing
tooth grinding, 34, 93
women, 23-25, 65
top, 310
work, 208-10
Topamax, 157-58
works, 311
topiramate, 157-58
trazodone, 106
trick, 310
triggers, 310 Xanax, 199
tweaking, 90, 310 Xanax XR, 103
twelve-step programs, 139-45, 265, 310
u
yoga, 221-23
UCLA (University of California), 23 Yoga Sutras of Patanjali, 221-23
UCSD (University of California, San Young, Eddie, 169
Diego), 23
UCSF (University of California at San
Francisco), 269
Unisom, 106 Zen Buddhism, 267
Universal Life Force, 227 ziprasidone, 165
Urschel, Harold, 162 Zoloft, 164
Usui, Mikao, 226-27 Zolpidem, 107

Zyprexa, 165
)
^, 3 9^99 05959 844 9
ti^g
Boston Public Library.
Sale of this material benefits the Library
^ The irst-ever practical guide to addressings'^
and overcoming addiction to crystal
methamphetamine , one of the widest spreading,
most addictive recreational drugs-în America—from
a Hew York City-based psychiatrist specialising
in the treatment of meth users.
Based on extensive scientific and social research and drawing from his professional
experience, Dr. vSteven Lee, a New York-based psychiatrist who specializes in crystal
meth addiction, provides an all-in-one guide to confronting and overcoming addiction to
this increasingly popular drug. Dr. Lee thoroughly and sensitively addresses all the crucial
questions crystal users (and their friends and caregivers) face:
What is crystal meth? How does it affect the body? How do you know if you re addict-
ed? How do you stop using? What if you don't want to stop? If you are going to use meth i
anyway, how can you minimize the damage? What if you quit, but sHpped and used again?
Overcoming Crystal Meth Addiction offers a comprehensive guide to everything meth
users and their friends and family need to deal with as they confront and seek to beat —
their addiction: i
ex agam without it
g crystal's role in your life
—
o stop using and how to stay clean Crystal and HIV
ing with self-esteem, depression, What to do if someone you know
social anxiety, ADD—and other life has a problem with meth
issues that can keep you turning Comprehensive resources
back t^ meth
STEVEN J. LEE, MD, is a physician in private practice in New York

City, specializing in addiction pvSychiatry. He is an Assistant Clinical^
Professor of Psychiatry at Columbia University, an affiliate of the /•
Addiction Institute of New York, a consultant ad4iction specialist at

the Callen-Lorde Community Health Center, and a consultant
HIV & AIDS.
psychiatrist at the Asian Pacific Coalition Against
He is American Academy of Addiction
also a diplomate of the
Psychiatry, an active member of the American Society of Addiction
Medicine, and a past member of national committees in the American
Psychiatric Association. He has published medical journal articles
on various topics is an editorial reviewer for addiction
in addiction,
medicine journals, and frequently lectures at national conferences
and medical centers about club drugs, the treatment of addiction,
and concurrent medical illnesses. He lives in New York City.
Marlowe & Company / Health I Addiction
An imprint ofAvalon Publishing Group, Inc;.
www.niarl()wepiil).coni
Croup West
t ( over design by Richard Rossilcr *
s\ Author photo^niph by Javier Agirstinelli

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^Petros levounis, MD, MA, Director,

The Addiction Institute of New York

crystal methamphetamine users and their families."

— Petros Levounis, MD, MA, Director, The Addiction Institute of New

"Finally! An unbiased, comprehensive, understandable book about crystal.

— Kat Coric, BFA, artist, AIDS activist

by normalizing methamphetamine dependency. It turns out that this addic-

— Patrick Moore, author of Tweaked: A Crystal Meth Memoir

"Overcoming Crystal Meth Addiction is a well written review of the history

at all of our facilities at Alternatives, Inc."

—Joseph M. Amico, MDiv, CAS, LISAC, President, National Association

Program Development and Community Educator, Alternatives Inc.

and mental health professionals — into a more contextual exploration of the

the underlying causes of crystal meth addiction. This book is an invitation to

a richer and fuller life, without addiction

—Jean Malpas, MA, LMHC, LMFT, psychotherapist

Marlowe 8c Company • New York

Copyright © 2006 by Steven Lee J.

Preface copyright © 2006 by Marc Galanter

in any form or by any means electronic, mechanical, photocopying, recording, or other,

Library of Congress Cataloging-in-Publication Data

Overcoming crystal meth addiction an : essential guide to getting clean from

Designed hy Pauline Neuwirth, Neuwirth Associates, Inc.

Printed in the United States of America

beautiful thing about being human

Preface by Marc Galanter, MD xi

PART 1: Understanding Crystal Methamphetamine:

1: Blue Meth, Super Ice, Crank, Tina, Chicken Feed: 15

2: What Exactly Is Crystal Methamphetamine? 28

3: How Is Crystal Made? 40

PART 2: Understanding Addiction:

4; Medical Disease or Weak Personality? What Is Addiction? 45

5: What Is All the Hype about Crystal? 49

j- Do You Think You May Be Addicted? 55

7: Taking a Look at Crystal in Your Life: 64

PART 3: How Can You Handle Crystal in Your Life? 85

I: What If You Use Crystal and You Don't Want to Stop? 87

Stopping Crystal— When You Feel That You Have

PART in Now That You Have Stopped Using,

11: Things You Can Do to Beat Crystal Addiction:

PART 5: Other Important Areas in Your Life That Can

13: Social Anxiety: When It's Difficult to Feel Comfortable

14: Depression: When Nothing Feels Good-

IS: Work: When You Need to Keep Your Job Performance

IJ: Attention-Deficit/Hyperactivity Disorder: You're Not

l7: Life Is a Balancing Act: Stress Management

11: Who Is in Your Social Circle? Dealing with Loneliness

and Finding a Sober Group of Friends

1 j: Crystal and Sex: If Sex on Crystal Is So Amazing,

PART 6: Special Topics

ZJ: What If You Slip? Does It Mean Failure?

21: You Are Who

22: Crystal and HIV: How Do They Affect Each Other?

23: What Do You Do If Someone You Know Has a Problem

APPENDIX 1 : Abstinence-Based Treatment and General 29

annually in health care and lost work. Furthermore, at least 20 percent of

units have addiction problems, many of which go undiagnosed. Despite

Basic research involving receptors, membrane chemistry, and genetic trans-

Japan in particular. Defense workers and civilians used amphetamines for

the removal of these nonprescription inhalers from the market. By then,

many parts of the country and in certain population subgroups. Within

American heartland, where it has gained considerable popularity because

Justin is a twenty-two-year-old high school graduate living in rural

powerful— he saw himself as a good-looking young man with the world