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Temas de actualidad / Current topics

In recent years the of America Use and of has experienced economic growth, low unemploy- ment, low inflation, and technological advances. -type However, coexisting with these favorable condi- in the United tions are underlying and underaddressed social in- equalities that may have an impact on patterns of States of America use and abuse of substances, including ampheta- mine-type stimulants (ATSs). For example, since 1975 most of the increase in national income has benefited people who are at the top 20% of the in- G. Cajetan Luna1 come range. There are disparities between those who do have and those who do not have the skills needed to thrive in a technologically dependent so- ciety, and the gap may be widening. New patterns of being seen in the United States may in part be explained by the increasing compe- tition to survive financially and interpersonally, the need that those failing to adapt to rapid technolog- ical change have to escape psychologically and ex- istentially, and the of the socially alienated and disenfranchised to self-medicate with ATSs and at least temporarily avoid social and economical inequities. According to the 1998 National Household Survey on Abuse, an estimated 13.6 million Americans were users of illicit (1). This num- ber is less than the 13.9 million estimated for 1997, and by comparison less than the highest level, in 1979, when the estimate was 25 million. With re- spect to stimulants in particular, the overall level of usage has remained constant, but increases have been observed in specific high-risk populations, who need focused outreach and intervention ef- forts. This article will focus on ATSs in the United States, including relevant demographic and cul- tural dimensions of their use and abuse, and sug- gested directions for future ATS research and pro- gram development.

ATS USE AND ABUSE IN THE UNITED STATES

Key words: Drug abuse, , United The history of ATS use and control States of America. For many decades in the United States pu- nitive actions have been taken against persons 1 AIDS Resources, Information, and Services of Santa Clara County, seeking substance-induced altered states of con- 380 N. First Street, Suite 200, San Jose, California 95112-4050, United States of America. Telephone: (408) 293-2747; fax: 408-293-0341; sciousness. These have ranged from the e-mail: [email protected] “prohibition” in the 1920s to the “drug bust” arrests

114 Temas de actualidad • Current topics of users in the psychedelic 1960s to the “war on States during the 1950s, large drug companies sold drugs” campaign of the 1980s. There are now more quantities of the drugs to bogus companies in care persons incarcerated in the United States for drug- of post office boxes. Known as “pep pills,” the related “crimes” than in any other country in the drugs were used for nonmedical purposes by many world. In 1997, 19% of prisoners in state facilities World War II veterans. In the 1960s, some doctors and 16% of those in Federal penitentiaries reported in San Francisco began prescribing amphetamine they had committed their current offense in order injections for treatment of . Other to obtain money for drugs (2). , known as “script writers,” would, for The desire to expand reality, to lower inhi- the cost of an office visit, write prescriptions for bitions, or to soften the consequences of unpleas- amphetamines. ant life circumstances has remained consistent, but ATSs came under new, stricter controls with the popular or preferred substances employed for the passage of the Federal Drug Abuse Control Sub- those effects have varied with succeeding genera- stances Act of 1965. Subsequently, that legislation tions. , alcohol, and marijuana are still the was consolidated with other laws into the Con- substances most widely abused by American chil- trolled Substances Act of 1970. That 1970 legislation dren and adolescents (3). regulates the manufacture and distribution of ATSs Various amphetamine compounds have been and other stimulants, as well as of , hallu- abused in the United States for over 90 years (4). cinogens, , and chemicals used in the illicit Amphetamines comprise a large class of stimulants production of controlled substances. and include ones produced and used both legally Further limitations on ATSs came with the and illegally. When used appropriately, ampheta- Federal Domestic Chemical Diversion Act of 1993, mines can help reduce deficit hyperac- which controls the diversion of and other tivity disorder, the most common psychiatric prob- legally obtainable chemicals for use in the illicit lem reported among children in the United States. production of controlled substances, including While widely prescribed for this disorder, amphet- and . Ephedrine are also frequently diverted from prescrip- is present in many easily obtainable, legal products, tion to recreational use. Amphetamines can elevate including ones used to control coughs, asthma, and mood, promote of , decrease inhi- allergies. Ephedrine occurs naturally in ma huang bitions, increase energy and , reduce the ( equisetina), and it is a and a need for , and suppress appetite (5). Users common ingredient in products for . have reported enhanced cognitive and physical abil- Ephedrine is structurally related to methampheta- it i es, as well as increased (6). mine, but ephedrine’s central ac- Among the legally produced pharmaceuticals tions are less potent. In 1995 the United States that are sometimes diverted to recreational use are and Drug Administration (FDA) mandated that (Ritalin) and (Pre- producers of bronchodilator drugs remove from ludin). Illegally produced “street” ATS drugs in- them ephedrine and related ingredients, including clude amphetamine (in slang called “black beau- ephedrine hydrochloride, ephedrine sulfate, and ties,” “white bennies,” “speed”) and such related racephedrine hydrochloride. The FDA acted in re- compounds as (“dexies,” sponse to a request from United States Justice De- “beans”), methamphetamine (“crank,” “crystal,” partment’s Drug Enforcement Agency (DEA) to re- “meth”; also “speed”), methylenedioxymetham- strict over-the-counter (OTC) use of bronchodilator phetamine (MDMA, known as “,” “XTC,” drugs because of their use as the primary precur- and “E”), and methcathinone (“cat,” “bathtub sor in the illicit synthesis of methamphetamine and speed,” “goob”). These illicit drugs can be con- methcathinone. sumed in different modes, including being taken A number of states in the United States have orally, injected, smoked, or snorted (inhaled into taken actions of their own to control products con- the nose). Injecting or facilitates an imme- taining ephedrine. Of the 50 states in the country, diate, intense sensation, called a “.” at least 14 of them have switched products contain- Since the early 1900s, amphetamine users and ing ephedrine to prescription-only status. Several abusers have tended to be white males, persons liv- states have introduced legislation that would ing in the western United States, and individuals tighten controls on ephedrine, phenylpropanol- working in blue-collar, transportation, or service- , and other used to il- related occupations. Other regular users and abusers legally produce ATSs. The attorney general of of amphetamine-type stimulants have included the state of Arizona plans legislation specifically athletes, college students, and those desiring quick limiting individual purchases of most ephedrine- weight loss. Although a prescription was required containing OTC cold and allergy (7). for the medical use of amphetamines in the United That legislation would limit purchases to 20 pack-

Rev Panam Salud Publica/Pan Am J 9(2), 2001 115 ages in a 24-hour period. A major national chain of dioxymethamphetamine (MDMA), which is com- retail stores already restricts the number of pack- monly known as “ecstasy.” Ecstasy causes mesca- ages of these products that their customers can buy. line-like psychedelic effects. First used in the 1980s, If a customer exceeds the limit, the cash register au- ecstasy is found in many major cities and suburban tomatically shuts down. areas of the United States. Relatively inexpensive, the drug is popular among the young. Continuous “techno” music, rampant ecstasy use, and a “uto- ATS usage patterns and populations at risk pian” togetherness fuel urban dance scenes, includ- ing energetic all-night “” that feature euphoric ATS abuse occurs among a wide variety of dancing and chemically induced “soul populations in the United States. Such users are expansion.” Clandestine by nature, raves are opti- predominately white middle-class teenagers and mally held in vast open-air environments, with the young . Amphetamines are also frequently location announced by promoters through flyers, used, in various forms, by male and female com- secret phone numbers, and Internet mailing lists. mercial sex workers (both street-based and through And while raves have declined more recently in organized call services), transgendered people, ha- some urban areas, they have grown in popularity in bitués of gay and straight , and college other sections of the United States, including even students. Frequent users also include rural migrant rural regions (15). farm workers, homeless persons, men who have sex Overlapping high-risk populations, which are with men, and members of motorcycle groups (8, at times part of the club and scenes, include 9). ATS use is increasing among women, African- highly mobile and disenfranchised street Americans, Hispanics, and Asians in the United present in many cities in the United States. Charac- States. terized by multiple body piercings, tattoos, and un- A number of problems result from ATS abuse. stable housing arrangements, these youth are fre- These include increased health care expenditures, quently avid users of crystal methamphetamine, premature from overdosing, impaired pro- either injected or smoked. Male and female sex ductivity due to chronic use, motor vehicle acci- workers were found to be heavy users of meth- dents, and and crime both as the result of amphetamine in San Francisco (14). A strong inter- ATS use and in order to obtain money to continue relationship exists between sex work and substance or maintain use. abuse, largely as the result of the accompanying Data from hospital emergency rooms are lim- lifestyles and behavioral characteristics. Many sex ited (9), but another source reports that between workers live an accelerated lifestyle, using alcohol 1997 and 1998 methamphetamine-related deaths and drugs that impair judgement. Substance abuse declined in the cities of Philadelphia, San Diego, is encouraged by irregular and late hours, multiple Seattle, and Honolulu, but they rose in the urban and sometimes disagreeable customers, and the areas of Minneapolis/St. Paul and Phoenix (10). need to relax inhibitions in order to participate in In recent years, illegal, clandestine laboratories undesirable sexual activities (16). Among gay and to produce methamphetamine have become com- bisexual male sex workers there is a particular pref- monplace throughout the United States, especially erence for injecting crystal methamphetamine since in remote and rural areas. These laboratories gener- injecting methamphetamine initially heightens sex- ate toxic and hazardous environmental wastes, in ual . Dancing, drugs, and sex are common addition to producing methamphetamine. features of weekend gay “white parties” (white There are numerous national and thousands of underwear or pajamas are the required apparel). local nongovernmental community-based organi- The West Coast cities where these parties are held zations addressing ATS issues throughout the include San Francisco, Los Angeles, and Palm United States. Such self-help groups as Narcotics Springs. A ritualistic character to Anonymous and Anonymous operate in among gay male partners exists when using most major cites (11, 12). ATS issues are usually ad- “speed” and is sometimes an integral part of re- dressed within existing substance abuse treatment lationship building, establishing , and - programs serving a full range of abuse issues, or making (14). Health officials report that in the South at treatment programs located within community Beach section of Miami ecstasy tablets sold at local hospitals. raves and clubs are mixed with other drugs in com- Ethnographic studies have found two drugs to binations known as “rolls,” which produce seesaw be endemic to the gay male club and circuit party and effects. scenes (7–9, 10, 13, 14). One is methamphetamine, According to the DEA, most methampheta- and the other is the “designer” drug methylene- mine comes from the West Coast, although illegal

116 Temas de actualidad • Current topics production labs and manufacturing sites have been and used in methamphetamine production (7). identified in most states of the country. The Na- Other easily obtainable substances used in the ille- tional Institute on Drug Abuse (NIDA) of the gal preparation of methamphetamine can include United States estimated that in 1996 there were iodine crystals, ephedrine, , pseu- some 1.46 million intravenous drug users (IVDUs) doephedrine, and pool acid (10). in the country (17). This number is considered an In the United States illegal ATSs are versatile underestimate, as it does not include the more than drugs, being taken orally, snorted, injected, or 1 million incarcerated people or 650 000 homeless smoked. The varies from people who are IVDUs (18). Most IVDUs are found city to city and from region to region within the on the East Coast of the United States, with the country. In addition, products called “look alikes” largest concentration in New York City (estimated or “act alikes” are being manufactured legally to be upwards of 250 000 persons). While metham- to resemble illegal amphetamines and to mimic phetamine is frequently injected, specific rates for their effects. These products usually contain vary- that mode of ATS use are unavailable. ing amounts of ephedrine, , and phenyl- Young males predominate in mortality and propanolamine. treatment indicators for methamphetamine abuse Another ATS, recrystallized methampheta- (7, 9, 10). Admissions to stimulant treatment pro- mine hydrochloride (“ice”), is very potent. It usu- grams are more often among persons 35 years of ally takes the form of clear crystallized chunks. It age or younger, in every city where information is induces a profound of euphoria by blocking available. In December 1998 the High School Senior the and stimulating the release of dopa- the Future Survey found that 10.1% of mine and noradrenaline in the central nervous sys- high school had used stimulants within the tem. Its use is typically followed by prolonged de- preceding 12 months, with the usage percentages pression and . When smoked, its effects can only being higher for alcohol (74.3%) and marijuana last up to 24 hours. (37.5%). Just over 60% of the youths surveyed re- In San Francisco, methamphetamine is put into ported that they could obtain amphetamines easily in what is termed “biker’s coffee.” This use is or very easily. Many of the youths interviewed who reported to be popular among young urban profes- used illicit substances did not consider ATSs to be sionals who want the drug’s energizing and ap- as harmful or addictive as cocaine or heroin. In re- petite suppressant effects but without having to cent years methamphetamine use has increased in snort or inject it. Some methamphetamine users the cities of San Francisco and Seattle, but has stabi- off the tops of light bulbs, put the drug into lized or gone down in the cities of San Diego and the glass bulb, heat the underside of the bulb, and Los Angeles. inhale the contents (9). In Houston, finely ground Increased methamphetamine availability and glass is mixed with methamphetamine. When in- abuse in diverse areas of the United States have haled, the mixture scratches the nasal linings, and prompted concern about its spread outside of the the drug is absorbed more quickly (7). In the west- areas of endemic use on the West Coast (7, 9, 10). ern part of the United States, predomi- Methamphetamine is an easily manufactured stim- nates in Los Angeles and Phoenix (7, 9). Smoking ulant. In 1998 the DEA identified 454 clandestine has increased in San Diego since 1997, replacing in- methamphetamine laboratories in just the three halation as the preferred route. is the most midwestern states of Missouri, Kansas, and Ne- common use route in Denver, San Francisco, Seat- braska. Many of these labs use precursor techniques tle, and cities in Texas. Inhalation and smoking are involving ephedrine or , making the preferred routes in the East and the Midwest methamphetamine easy to synthesize and requiring (10). Amphetamine in powder form is common to little or no previous knowledge of drug chemistry. the dance scene. It is sometimes dabbed with a fin- Methamphetamine is typically inhaled or put ger onto the gums (this eventually rots the teeth), into , and sporadic injection use has been re- may be added to alcoholic drinks, or is “bombed” ported (7, 9, 10). Phenmetrazine (Preludin) is avail- (wrapped into a paper and swallowed). able in the North Side section of Chicago, where users inject the drug. Ecstasy use was reported most often among young adults and adolescents at dance Social and cultural contexts influencing clubs, raves, and rock concerts in Atlanta, Miami, ATS abuse St. Louis, Seattle, and in Texas cities. The DEA has reported that in the city of Phoenix, Arizona, there Public health ATS interventions must reflect is an emerging production technique whereby road an incipient appreciation for the role that social re- flares containing phosphorous are ground up lations, culture, and “meaning making” (explana-

Rev Panam Salud Publica/Pan Am J Public Health 9(2), 2001 117 tory models) have on patterns of ATS-related risk. phan hydrobromide (DXM). Many popular OTC The association between subculture and ATS abuse cough-control formulas include DXM. is most pronounced among youth. Ethnicity, so- cioeconomic status, sexual orientation, musical preference, and the high school attended (geo- Legal pharmaceutical products and ATS abuse graphical and environmental determinants) all in- fluence youths’ access to and choice of ATSs (8). In the United States the Food and Drug Ad- American street youths, ravers, truck drivers, and ministration (FDA) has the primary responsibility motorcycle groups all function in different socio- for approving and monitoring pharmaceutical cultural niches, each with its own shared space, products, including legally produced ATSs. The identifiable leaders, shared rituals, and adherence FDA often works in concert with the Justice De- to specific codes of behavior. Homosexual or gay partment and the DEA to help identify and control communities, for example, can be found in every the production of illegal ATSs. In 1992 the United major city in the United States and in most other States Congress passed the User major cities of the world. These communities have Fee Act, which provided additional resources to social, commercial, and political functions. In the expedite the FDA’s review and approval of new United States the communities have gay businesses, prescription-drug applications (22). Subsequently, bars, athletic centers and gyms, social service cen- the FDA established the Adverse Event Reporting ters, phone-sex lines, computer bulletin boards, and System, a medical watch program, to gather and churches that are easily accessible and that may evaluate spontaneous reports of post-approval serve as locations for ATS acquisition or use (8). It problems. is estimated that 10 000 gay men in Los Angeles In 1997 the FDA responded to health compli- use methamphetamine regularly, maintaining social cations and deaths in the United States that were networks that facilitate their drug use practices and linked to OTC diet products that contained ATS de- activities associated with their gay identity (19). rivatives (22). Weight loss products and services Another important aspect of ATS use in the in the United States make up a market worth some United States is the abuse of additional drugs, most $33 billion annually. A rise in rates in the often alcohol and marijuana. Furr and colleagues county could lead to an increase in the use of both (20) reported a strong relationship between daily prescription and OTC diet drugs. The prevalence of and smoking “ice.” According obesity in the United States rose from 12% in 1991 to the NIDA Community Epidemiology Working to 17.9% in 1998, and obesity is now related to some Group (7, 9, 10), marijuana is the most common 300 000 deaths a year (23). “secondary drug” in San Diego, Chicago, and Houston. Alcohol is the preferred secondary drug in San Francisco and Boston. In Miami, cocaine is Health and psychosocial consequences of the most common secondary drug, and heroin is ATS abuse the most common “tertiary drug.” In Chicago and elsewhere, stimulant users may inject a combina- Chronic ATS abuse can lead to significant so- tion of methylphenidate (Ritalin) and heroin. Street cial, occupational, and medical impairments (24). outreach workers in the city of New Orleans, The immediate effects of ATS overuse include in- Louisiana, report that ecstasy is injected with co- creases in talkativeness, aggressiveness, breathing caine and (Nubain), a synthetic rate, heart rate, and pressure. ATSs can also similar to . Other reports men- produce visual and auditory hallucinations. ATS tion frequent mixing of ecstasy with other drugs: injecting is believed to be the route of administra- LSD (“candy flipping”), psychotropic mushrooms tion associated with most health-related ATS prob- (“flower flipping”), and heroin (“H-bomb”). Some lems and such social harm as violence and crime. bisexual or gay men use ecstasy in combination The actions of persons taking ATSs often be- with isobutyl nitrate (“”) during sexual ac- come compulsive, repetitive, less organized, and tivity, which increases the heart rate, blood , the users themselves suspicious and self-conscious and sexual excitement and also allows for relax- (24). Large ATS doses can cause and sweating, ation of the anus without loss of erection. dry mouth, headache, paleness, blurred vision, Among amphetamine users who want to dizziness, irregular heartbeat, , loss of coor- soften the euphoric “high” coming from ampheta- dination, grand mal , and even collapse. mine and to allow for sleep, a variety of relaxants Chronic abuse effects include mental illness similar are often subsequently employed (21). These can to paranoid , as well as malnutrition, include diazepam, , and dextromethor- blockage of blood vessels, increased susceptibility

118 Temas de actualidad • Current topics to illness due to poor diet, and lack of sleep. youths had engaged in amphetamine use in their may occur spontaneously due to burst blood ves- lifetime, and 21% of those studied were current sels in the , heart failure, or high fever. How- users. The youths who had used amphetamines ever, making direct linkages between these out- had had more sexual partners and sexual encoun- comes and ATS use is difficult because of many ters in their lifetime and had engaged in more risky users’ polydrug habit and ATS lifestyles often char- behaviors than those who had never used amphet- acterized by reduced nutrition and adverse rest amines. The amphetamine users were less likely to patterns. Babies of mothers who abuse ATS may use condoms during sexual activities, and more be born with neurobehavioral abnormalities, low likely to inject drugs and share needles. Rotheram- birthweight, cardiac defects, cleft palate, addiction, Borus et al. (13) graphically described the plight of and withdrawal effects. these young people and the significant HIV risk Johns Hopkins University scientists report that they face: heavy ecstasy users show a significant decrease in brain cells responsible for reabsorbing , a Initially, new users characterized their experience as a messenger chemical involved in mood, appetite, heightening of sexual arousal. Youths on the West , sexual drive, and memory (25). Coast frequently had “runs” of the drug. YLH Dancing for long periods of time while using ec- [youths living with HIV] would use amphetamines, especially methamphetamine, for 2 to 4 days, during stasy dehydrates the body and inhibits the body’s which time youths reported prolonged periods of ability to maintain a normal temperature, with sexual arousal, multiple sexual partners, and feelings most ecstasy-related deaths resulting from those of euphoria. This “high” was followed by a crash, two effects (26). Because long-term methampheta- characterized by a period of , feelings of mine use can produce extreme paranoid despair, and a lack of sexual desire; such symptoms (drug-induced ), some methamphetamine prompted youths to seek another high and to reiniti- addicts are initially seen by or psy- ate use of amphetamines. However, over time the chiatric units instead of drug treatment programs. arousing qualities of the drug decreased; youths, par- A problematic use cycle exists for regular metham- ticularly young gay men, reported difficulty in phetamine use, according to Rotherm-Borus and achieving sexual arousal and were uninterested in colleagues (5): sex. A constant state of depression resulted among youths [who] were using the drug. Thus, habitual users of methamphetamine reported being unable Methamphetamine use can provide youths with an to have sex without it, and craved the drug when illusion of excitement and satisfaction in their lives. having sex, indicating that there is a cycle of use that Initially, it is a means to an end: to get high, to in- will have periods of greater and less risk for HIV crease sexual with others. Eventually, transmission. chronic use becomes an end in itself, as waking hours are spent from one run [continuous and accelerated use] to the next and all efforts are geared towards Other research as well indicates the link be- getting more drugs. Instead of sexual potency, sexual tween ATS use and HIV . A San Francisco dysfunction results; instead of intimacy, further iso- study of intravenous drug users (IVDUs) found that lation and occur. The developmental tasks the highest HIV seroprevalence (20%) occurred that face all youth are distorted or retarded. Meta- among IVDUs whose primary drug was metham- phorically and in reality, methamphetamine use is phetamine (8). “Speed” users were found to have equivalent to going nowhere fast. problems recognizing HIV risks when using drugs and engaging in unprotected sex (14, 28). A 1993 HIV infection and ATS abuse NIDA study (8) found that injecting methampheta- mine was associated with increased sexual activity. There is a clear connection between ATS abuse The study also identified “speed” as the “quintes- and HIV infection, most significantly for users who sential gay drug because its pharmacological prop- inject ATS drugs and risk HIV and hepatitis A in- erties contribute to sexual intensity.” In a study of fections from using shared or tainted needles (27). gay and bisexual male drug users in Hollywood, re- ATS use also reduces inhibitions, breaking down searchers found that, in comparison to those not individuals’ psychological and sexual barriers. This using methamphetamine, methamphetamine users was shown, for example, in another study by were less likely to use condoms when engaged in Rotheram-Borus and colleagues (13). They con- high-risk sexual behaviors and were more likely to ducted psychosexual and substance abuse assess- have used other drugs within the previous 30 days ment interviews with 337 youths living with HIV in (29). Gulati and colleagues (30) studied two cohorts New York City, Los Angeles, Miami, and San Fran- of methamphetamine users in southern California cisco. The researchers found that 38% of these (one heterosexual, the other gay/bisexual) and

Rev Panam Salud Publica/Pan Am J Public Health 9(2), 2001 119 found a strong connection between methamphet- make other dramatic lifestyle changes. Harm-reduc- amine use and HIV risk behaviors, especially for tion approaches attempt to minimize the harm heterosexual users who believed they faced little risk brought about by drug abuse, even if drug abuse of infection. An ethnographic study conducted in cannot be completely halted. One harm-reduction San Antonio, Texas, recommended increased risk- strategy is to combine or replace the drug of choice reduction efforts targeting methamphetamine users. with drugs that are perceived to be less harmful, The researchers found that less-sweeping behavioral such as replacing methamphetamine with mari- changes are needed to reduce needle-related HIV juana. Behavioral changes may involve balancing risks for “speed” users than for heroin users (31). the drug “clean-up times” with “mess-up times” and in the process attempting to maximize the “clean-up” periods. New areas of in the field Treatment for ATS abuse of chemical are the and neuropathology of addiction. The discovery of opi- The exact number of people being treated for oid receptors has raised the possibility that depen- ATS abuse is difficult to estimate in the United dence and tolerance might be explained in terms of States since there are few facilities that provide changes in these receptors, with the potential for ATS-specific treatment. Instead, ATS abusers are more effective chemical treatment of addiction. referred to treatment facilities that provide services Providing effective treatment for hidden or for a wide range of substances, including ATSs. marginalized populations can be especially hard. In Methamphetamine users are often overly ex- an explanation that may apply to other difficult-to- citable and extremely resistant to any form of inter- reach groups in the United States and elsewhere, vention (32). The catalyst for most methampheta- Gorman and his colleagues (8) describe the chal- mine users to enter treatment is police intervention lenges of serving members of the gay community brought on by the users’ aggressive behaviors, fight- who use “speed”: ing, or other bizarre or inappropriate conduct. Peo- ple arrested under the influence of methampheta- Gay and bisexual men who use speed remain largely mine are some of the most difficult to manage due hidden from mainstream society, from the usual sen- to high levels of , agitation, and paranoia. tinel drug surveillance points, and even from the gay community and their own partners and support sys- ATS abusers must make dramatic life changes tems. Gay and bisexual speed users typically are mid- in order to stop using the drugs (5, 14). In a study dle or working class, and are more likely to be Cau- comparing cocaine users and methamphetamine casian, Asian, or Latino. They are more likely to live users in San Francisco, Copeland and Sorensen in gentrified neighborhoods in gay-identified geo- (33) found that the two groups did not differ in graphic communities, and are unlikely to end up in treatment compliance, as measured by clinic atten- jail unless they are caught drug dealing. They may dance, drug-free urines, and successful completion hold a job for years, in part because they may only use of treatment. The researchers recommended that re- drugs occasionally, and not to the extent that there is sources should be directed toward addressing interference with job performance. Once they admit “” issues of multiple physical and they have a problem with speed, they may once again become invisible because there are few if any treat- mental health problems and toward providing an- ment programs designed for methamphetamine cillary support services. abusers. Many users may be referred to 12-step pro- ATS treatment in the United States is similar to grams such as NA [] or to gen- that for other controlled substances (34). Treatment eral treatment programs that attempt to address the varies from in-patient 24-hour care to weekly or needs of individuals with a variety of other substance monthly community-based support groups. Pro- abuse issues and from a variety of cultural and eco- grams often apply such techniques as pharma- nomic backgrounds. A further disincentive is that, as cotherapy, psychoeducation, behavioral interven- gays, they may be fearful of disclosing their sexual ori- tion, skills training, and case management. entation to the treatment program, or they may Treatment often focuses on prevention and being told it is irrelevant. An additional on the “12-step” approach to social recovery that may arise if they have HIV/AIDS since they may feel even more uncomfortable disclosing information has been used by such groups as Alcoholics Anony- about sexual behavior in the context of drug use. mous and Narcotics Anonymous. Treatment modalities can vary from “tough love” total cessation models to alternative, holis- RECOMMENDATIONS harm-reduction behavioral modification ap- proaches (34). Strategies can include efforts to coun- The recommendations offered below supple- teract drug effects, improve diet, provide , ment ones generated at the World Health Organi- and see that users get more sleep or even relocate or zation Meeting on Amphetamines, MDMA and

120 Temas de actualidad • Current topics Other Psychostimulants, which was held in No- unreachable through in-person venues. Evalua- vember 1996 in Geneva, (35). While tion should be conducted on the quality of the in- many Latin American countries have conducted formation exchanged, its dispersal, and on pri- drug use surveys, little of the resulting information mary and secondary ATS prevention education focuses on ATS use. These recommendations are targeting middle- and upper-class populations. primarily intended for the United States and Canada, but other countries in the Region of the Acknowledgements. This paper was con- Americas may find them applicable as they also tracted for and presented in a longer version at come to face similar problems with ATS abuse. the Second Conference on Amphetamine-Type Stimulants, November 1999, Bangkok, Thailand, • To better explain factors that contribute to World Health Organization (SAB/A2/370/36- ATS use, studies must be designed that are HQ/99/603315). The author gratefully acknowl- age-specific, developmentally appropriate, and edges the suggestions of Maristela Monteiro, Eve- culturally sensitive. In addition to focusing on lyn Eisenstein, Marie Teach, and Josue Ferreira. traditionally overstudied marginalized or disen- franchised populations, attention should also be focused on ATS abuse among more affluent groups, given that technological change may SINOPSIS promote increased competition and encourage greater ATS abuse among such groups. Uso y abuso de estimulantes anfetamínicos en • Comparative studies should be conducted spe- Estados Unidos de América cifically on the of treatment programs em- ploying ATS harm-reduction models versus ones En los Estados Unidos de América, la popularidad de los requiring total ATS cessation (36, 37). compuestos anfetamínicos de consumo legal e ilegal, junto • An assessment must be made of ATS abuse coun- con las prácticas de uso y abuso que con ellos se asocian, seling interventions at such gathering places as variado a lo largo del tiempo y en distintos lugares. Estos compuestos, que en épocas anteriores evocaban la imagen de schools, concerts, raves, and dance clubs, as well obreros blancos de sexo masculino y de personas que seguían as street corners and other locations where sex regímenes dietéticos de moda para adelgazar, actualmente workers and ATS users congregate. son consumidos, a menudo en cantidades excesivas, por po- • Interventions should be tested where ATS users blaciones más diversas y numerosas. La magnitud de este are assisted in identifying and chronicling their uso y abuso de anfetamínicos, que fluctúa según la zona geo- behavioral patterns and activities. Repeated and gráfica y el ambiente social y cultural de la localidad, puede consistent interventions are needed to raise con- cambiar paulatinamente. Los estimulantes anfetamínicos sciousness of drug use and sexual activities. Mo- (EA), especialmente la metanfetamina, son ubícuos en los tivation for behavioral changes can also come establecimientos nocturnos donde se reúne a bailar la juven- from setting career goals, identifying employ- tud en los Estados Unidos. El uso y abuso diseminados de ment opportunities, and establishing specific estas sustancias se observan en poblaciones que consideran menos peligrosos a los EA que a otras sustancias como la co- plans for the future. caína y la heroína. Entre estos grupos de usuarios se en- • Longitudinal descriptive field studies are needed cuentran los jóvenes que carecen de representación social, to follow ATS users and ascertain the strategies los homosexuales, los bisexuales, los trabajadores del sexo y they have used to moderate or discontinue their los estudiantes de bachillerato y universidad. Los EA son drug abuse. Attention must be focused on identi- relativamente baratos y se fabrican fácilmente en los Estados fying the “turning points” that allow ATS users Unidos. Por consiguiente, es probable que estas drogas sigan to change their habits, and on the windows of op- siendo codiciadas y disponibles en el mercado ilegal por portunity for service interventions. Evaluations muchos años más. Dado que el uso y abuso de EA son, en are also needed of interventions that relocate gran parte, prácticas ilegales y clandestinas en los Estados ATS-addicted people from drug-saturated com- Unidos, resulta imposible enumerar todas las poblaciones que usan EA o que abusan de ellos. Hacen falta estadísticas munities to neighborhoods or sheltered living y sistemas de información más exactos, mejor coordinados y situations where there are such life alternatives de base poblacional para poder identificar los patrones de uso or empowerment initiatives as continuing educa- y abuso de EA y sus tendencias. Esta revisión se apoya en tion and job and technical skills training. varias fuentes de datos para delinear los aspectos demográfi- • Additional and innovative uses of the Internet cos y culturales del uso y abuso de EA. El trabajo también for ATS informational and educational purposes señala el rumbo que deben seguir los estudios sobre EA en el must be explored (35). The Internet offers the op- futuro y los programas de control. portunity to connect with people who are often

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122 Temas de actualidad • Current topics