The lonely drug: crystal meth in the UK

This article originally appeared in HIV Treatment Update, a newsletter published by NAM between 1992 and 2013.
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There are increasing signs of problematic methamphetamine use amongst some gay men in the UK. Gus Cairns reports.

What is methamphetamine?

Methamphetamine – meth, crystal, ice, tina, Christine, yaa baa, Nazi speed - is a chemically altered version of amphetamine (speed). Amphetamine was first synthesised in 1887 and marketed from the 1930s to 1960s as a decongestant and slimming aid. It keeps people awake and leads to a heightened sense of euphoria and self-confidence. It was banned in the UK in 1964 and the USA in 1971.

Glossary

stigma

Social attitudes that suggest that having a particular illness or being in a particular situation is something to be ashamed of. Stigma can be questioned and challenged.

harm reduction

Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use (including safer use, managed use and abstinence). It is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs.

withdrawal

In the context of drugs or alcohol, withdrawal is when a person cuts out, or cuts back, on using the substance, also known as detoxification or detox. In a context of sexual risk reduction, it refers to the insertive partner in penetrative sex withdrawing before ejaculation. It is not a particularly effective way to lower the risk of HIV transmission or pregnancy.

psychosis

Mental health problems that stop someone from thinking clearly and telling the difference between reality and their imagination.

depression

A mental health problem causing long-lasting low mood that interferes with everyday life.

Methamphetamine was synthesised in 1918 and was distributed by the Nazis, who thought it would make the ideal keep-awake pill for the armed forces (other countries used it too). It was banned in Germany just three years later. It certainly kept soldiers battle-ready, but it also took days for them to get over the exhaustion it caused. From the start, it had a bad reputation.

Amphetamine drugs cause the nerve cells to release heightened amounts of the neurotransmitters dopamine and serotonin. Dopamine provides elementary pleasure and energy while serotonin boosts self-esteem. Amphetamines wring the dopamine out of nerve cells, and it takes days for them to start producing normal levels again. At the peak of a methamphetamine high, you’ll have about 12.5 times the normal amount of dopamine in your brain. That’s why the rush is so fierce and long.

It’s a drug of abuse across the world, and not just amongst gay men. There’s an association with sex: south-east Asia has had a problem with yaa baa (‘mad pills’ in Thai) since the early 1990s, and sex workers and their trucker clients were the first consumers there. In one US study1 heterosexual men who used meth were twice as likely to have sex with multiple partners as non-users.

Gay men and meth

In the global north, however, the phenomenon that has caused the most alarm is the epidemic of crystal meth use that started amongst gay men in the western USA in the early 1990s, spread to the east coast around 2000, and shows signs of becoming a problem in London’s gay scene now.

Coverage of meth, especially in the USA, bordered on the hysterical to start with. This community alarm was countered in other quarters by a cautious response that some saw as complacent.

One factor is that meth use is high, not amongst all gay men, but amongst very specific populations of gay men, and not everyone is equally vulnerable to developing dependency. Few researchers have examined exactly why some men are so fiercely attracted to this drug, and others immune to its thrills.

Research has tended to concentrate on the medical damage caused by the drug: its association with HIV infection, poor adherence, and drug resistance. But some think it is the psychological and social consequences of meth use that are more important: psychological illness and an often rapid disintegration of a stable lifestyle.

How many use it?

In the USA, meth use in gay men may have passed its peak. Initial reports on a Centers for Disease Control survey2 suggest that in New York the proportion of gay men who used meth at least once a year peaked in 2004 at 14%. Four years later the figure was 6%. In harder-hit San Francisco, meth usage declined from 22% to 13% in the same period.

In the UK, the Gay Men’s Sex Survey in 20053 found that only 3% of the whole sample had used methamphetamine and that only 0.3% were frequent users of the drug. Usage amongst certain groups was much higher, though. In London gay men it was 7%; amongst HIV-positive gay men in London it was 20%; and in HIV-positive men with multiple partners it was 35%. Frequent use was rare, however. Another survey in 2003-05 found that 20% of users of London gay gyms had used methamphetamine in the past year.4 However, three-quarters of users said they’d only used the drug once or twice. Only eight out of 750 men surveyed used it once a week or more.

Statistics from both London and New York show a dichotomy between little or no use amongst most gay men, but considerable use in a few.

In New York a study looking at 450 gay men who used drugs on the club and party scene found that 65% had used methamphetamine in the last four months.5 But there was considerable variation in use - a lot of men were managing a lifestyle involving use every few weeks, while a minority would be either high or coming down most of the time.

Methamphetamine and HIV

There is a clear association, at least from US studies, between methamphetamine use and HIV infection. A study from San Francisco in 20056 estimated that the annual HIV incidence rate amongst gay men testing for HIV was 2.5%, but was 8% amongst meth users – explained by the fact that meth users were 2.3 times more likely to have unprotected anal sex.

Studies have found much higher HIV treatment failure rates in methamphetamine users: one study in 2007 found that less than 40% of meth users on HIV treatment had an undetectable viral load compared with over 60% of non-users. But people not on HIV treatment had similar viral loads regardless of meth use, showing that the difference in treatment success was due to meth causing adherence problems rather than to any direct effect on HIV.

The key problem with meth use for the gay community is the length of its effect and its comedown. People may take too much of other drugs, such as alcohol or cocaine, (and this will eventually tell on their health), but generally they can still hold down a job and have the basics of a structured life. But a drug that keeps you up for days, followed by an equally lengthy period of major depression, is much more difficult to reconcile with a normal lifestyle.

The early response

Campaigners felt that publicly funded gay men’s sexual health agencies were slow to respond to meth in the USA and the same accusation has been directed at organisations in the UK too. In the USA, Peter Staley, a former bond trader and founding member of ACT-UP, launched a controversial anti-meth campaign when the gay men’s health organisations wouldn’t do it.

“I’m not anti-drug,” he told the US PBS network in 2006, “but this is a different beast…We are seeing people with white-collar jobs, the boyfriend of 15 years, the two dogs, the Manhattan condo, losing everything in six months. Being able to handle other drugs before is no guide to whether you’ll be able to handle this one.”

He tells HTU that the link with sex is crystal’s real hook: “People say ‘Try this, you’ll have the best sex of your life,’ and unfortunately, there’s quite a bit of truth in that…because it lowers inhibitions.

“If you happen to have great sex on crystal the first time,” says Peter, “It can set up major problems. Your brain wants to repeat that first high.”

The peak age for getting into meth is 35 to 45, and HIV-positive men are much more likely to use it. Understandably, they’re also the group of gay men more likely to experience sexual dysfunction, the fear of rejection, and poor body image. Meth crashes through those inhibitions and can make you feel like a porn star. Until the comedown.

The nearest equivalent to Staley in the UK is probably Gary Leigh, who set up the internet site LifeorMeth.com after he “witnessed the pain and degradation inflicted on friends and acquaintances by meth” in the USA.

Drug projects in the main do not see many gay men, and they’re also not used to dealing with a situation where sex and drug addiction are reinforcing each other.

Flick Thorley, clinical nurse specialist for HIV and mental health, Chelsea and Westminster Hospital

The deterioration was particularly noticeable around 1998, he says, when Viagra arrived, overcoming a side-effect that had previously put a lot of men off meth – ‘crystal dick’ erectile dysfunction.

He got very frustrated with the lack of interest he perceived in gay men’s sexual health organisations. “Armed only with anecdotal evidence and not the scientific proof they were demanding, I found myself stumbling around in the dark.”

He insists that any message other than total abstinence from meth will confuse gay men – not a message drug agencies who aim at harm reduction would necessarily agree with. “By aiming different campaigns at different levels of user you risk sending out mixed messages. The universal message has to be non-negotiable -don’t use crystal!

Is the problem increasing in the UK?

We have few hard data on current trends, only increases in demand noticed by some London agencies.

Flick Thorley is the clinical nurse specialist for HIV and mental health at the Chelsea and Westminster Hospital in London. A soon-to-be published survey found that 25% of gay men attending the Chelsea and Westminster Hospital’s sexual health clinic said they had used crystal. More data will be published soon.

She doesn’t feel that much could have been done to prevent the current increase in use, but sees an urgent need for new types of services to help increasing numbers of meth casualties.

“I don’t see people until they’re really on their knees,” she says. “By the time people come here they may be displaying overt psychosis or their social network has completely disintegrated.

“Drug projects in the main do not see many gay men, and they’re also not used to dealing with a situation where sex and drug addiction are reinforcing each other.”

She is also concerned that gay meth users are moving rapidly from smoking the drug to injecting it – as happened in Australia. One co-infection specialist told HTU he thinks that a significant proportion of hepatitis C co-infections in gay men may be due to injecting drugs.

The message has now got through to health charities. Gordon Mundie, gay men’s group worker at the Terrence Higgins Trust (THT), is one of a new generation of gay men’s health workers who have started to witness increasing damage. 

“THT was running a group for gay men with drug problems called Are You Losing Control? till the end of last year, when it lost funding. It wasn’t aimed at meth users but suddenly they started to dominate – at one point we had a group of eight, five of whom were injecting meth users.

“Men are not reporting problematic use till it’s way out of control. They don’t believe they can talk about drugs to HIV workers, they don’t want it on their records, and criminalisation of HIV transmission comes up regularly as a reason not to talk. I think there’s a clear discrepancy between the numbers…reporting problems and actually having ones.”

A particular problem, explains Mundie, is combined use with the drugs GHB and GBL (gamma-hydroxybutyrate and gamma-butyrolactone). You can’t sleep on crystal but you may be able to if you add GHB, and it can take the edge off meth paranoia. Unlike methamphetamine, GHB and GBL produce physical dependency and withdrawal symptoms. Some of the symptoms experienced by meth users in crisis may be caused by GHB withdrawal.  

There are signs that statutory agencies are now responding and THT is putting together a proposal for funding for a much more comprehensive counselling, support and recovery programme for gay men, which will include measures not previously considered necessary for the gay community, such as residential drug rehabilitation. “Should we have anticipated this before?” Mundie asks. “Absolutely.”

The proportion of gay men turning up at Antidote, the LGBT service at the Hungerford Drug Project in London, who cite crystal as their main problem is increasing. The project has been in talks with the police and the Home Office about how to handle the growing problem and, like THT, are hopeful of more government support.

I talked there to Monty Moncrieff, client services manager, and David Stuart, a volunteer who works with men with meth problems.

Between 2005 and 2008, the number of men contacting Antidote with drug problems increased by 42%. 2005 was the first year any of them cited meth as the problematic drug: 5% of the total. By 2008 this had tripled to 15% and by September 2009 this had gone up to 20% of clients. Since then, the proportion with meth as their main problem has continued to climb.

David explains: “Meth is not a drug men use to deal with shyness or social unease, as they might with cocaine. It’s all about gay men’s feelings of sexual inadequacy.” The ‘benefit trap’ generation of HIV-positive gay men, dealing with unprocessed grief, deskilling, lost opportunities and stigma, is particularly vulnerable.

Antidote thinks there’s room for differing, harm reduction messages in meth education and doesn’t support the ‘total abstinence and nothing but’ line.

“You need information on meth for people contemplating its use, not glamorising it or frightening people, but emphasising its dangers. But once someone has started using, no amount of horror stories in themselves will stop people using it. Users will feel it doesn’t apply to them. They’ll think ‘I know more about this drug than any pharmacist’. In gay society there’s a stigma about not being able to ‘handle your drugs’, and they’ll just think ‘No way am I one of those sad losers’.”

The method Antidote has adopted so far is essentially a slow process of socialisation.

David says: “Gay men take it initially so they can lose their inhibitions about connecting with other gay men and yet ironically, more than any other drug, meth isolates its users. Our users usually turn up sober – and devastated. Shame is a major barrier.”

Monty says: “What we do is provide a space where they can experience being normal and calm again. We offer support groups, massage so they can experience non-sexual touch, just a space for people to be. At first many users are paranoid and don’t want to socialise. Gradually they’ll start talking about their experiences. There will likely be many relapses before people stop using. We help them plan for trigger times like public holidays.”

Learning to have non-drug-fuelled sex is the worst problem facing many users, because sexual attraction will set off cravings. “Many people abstain and only slowly learn about being able to combine sex with an intimacy they might never have had,” says David.

They don’t see shortcuts to reducing meth use. “Ultimately, the only answer is to have a more esteemed and confident gay community.”

"I hated it"

Stewart Who is a DJ and former editor of QX Magazine.

I first came across crystal in San Francisco in the mid-90s. I just bought some because everyone else did. I assumed it was like coke.

I had a horrible time. It’s a really boring drug. There’s no buzz on it – you just can’t blink. You could be on other drugs and it kind of flatlines their effect.

You become hyperaware, and slightly dissatisfied with whatever is going on…You think the next thing is going to satisfy you and it doesn’t. That applies to the sex too. After two hours you want to cum and you can’t. It becomes mechanical.

The comedown was monstrous. I thought I’d be OK after the first day, but every day was a new level of awfulness. The despair and hollowness is just unparalleled.

It’s got this bad-boy reputation – how close to the fire can you go?

I’ve known successful people who’ve lost their jobs, lost their money – real junkie behaviour – stealing and lying. You may think you can manage it but sooner or later you’ll end up living in your car.

How do people get over it? You have to value a normal life again. Take pleasure in having food in the fridge, a tidy flat, and a walk in the park on a summer’s day.

But it’s hard to sell that till you’ve lost it.

 

"I loved it – too much"

Pete is an ex-escort who used crystal for ten years and now helps other gay men with meth problems.

I became an escort because I wanted to be like the popular, sexy, interesting people I met in gay clubs. I was soon diagnosed with HIV at 21.

I had a very repressed upbringing. Sex was just currency to me, I couldn’t ask for pleasure.

I came across crystal when I was 28. Someone noticed I was twitchy and said “Take this, you’ll feel more confident.” Well I did! I could finally say to guys “Do this to me, I like it”.

I was on it for ten years. I was getting really lonely going from one sexual encounter to another, but the solution to loneliness was to go out and find more.

Eventually lack of sleep and isolation led to psychosis. I thought people were watching me and insects crawling under my skin. I realised I had to get help.

It took me two years to get sober, two years to get that much of a rush out of life.

Today I have amazing sex because I date people! I get to know them. I say “I want to feel really safe and intimate and familiar before we have sex”. I don’t have the fear of being judged – are my muscles good enough, will I lose my erection? – that I did before.   

My goal is to nurture this work, have a busy life, a relationship, and a pension. Normal stuff I never had before.

For information and support contact:

THT Direct: 0845 1221 200

info@tht.org.uk  

Antidote @ The Hungerford (London)

020 7437 3523

www.thehungerford.org/antidote.asp

 

References

1. Morbidity and Mortality Weekly Report. Methamphetamine use and HIV risk behaviors among heterosexual men: preliminary results from five northern California counties, December 2001--November 2003. MMWR 55(10);273-277, 2006.

2. Staley P Studies show huge drop in meth use among gay men in NYC. See http://blogs.poz.com/peter/archives/2010/01/studies_show_huge_dr.html

3. Hickson F et al. Consuming passions: findings from the United Kingdom Gay Men’s Sex Survey 2005. Sigma Research, 2007.

4. Bolding G et al. Use of crystal methamphetamine among gay men in London. Addiction 101(11:1622–1630, 2006.

5. Halkitis PN et al. Poly-club-drug use among gay & bisexual men: a longitudinal analysis. Drug Alcohol Depend 89(2-3): 153–160, 2007.

6. Buchacz K Amphetamine use is associated with increased HIV incidence among men who have sex with men in San Francisco. AIDS 19(13):1423-4, 2005.

7. Colfax G et al. Frequent methamphetamine use is associated with primary non-nucleoside reverse transcriptase inhibitor resistance. AIDS 21:239–240, 2007.