2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 1

A Four-Pillars Approach to Methamphetamine

Policies for Effective Drug Prevention, Treatment, Policing and Harm Reduction

Bill Piper Director of National Affairs 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 2

A Four-Pillars Approach to Methamphetamine: Copyright © March 2008 Policies for Effective Drug Prevention, The Drug Policy Alliance Treatment, Policing and Harm Reduction All rights reserved Bill Piper Printed in the United States of America

This report is also available in PDF format on the Drug Policy Alliance website: www.drugpolicy.org/meth

“Being addicted is being addicted. Meth wasn’t my problem. Addiction is my problem. But [with treatment], I’ve been sober for three years.” Cynthia, Escondido, CA

No dedicated funds were or will be received from any individual, foundation or corporation in the writing or publishing of this booklet. 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 3

Table of Contents

Executive Summary 2

Four-Pillars Policy Checklist 4

Introduction 6 • A Brief History of Methamphetamine in Society • Moving Beyond a ‘Drug War’ Approach • Facts about Methamphetamine Use • Perpetuating Old Myths Only Makes Matters Worse

Prerequisites for Sucesseful Drug Policy 9 • Supply-side Strategies: Wasteful and Misguided • Treatment, Not Incarceration, Can Keep Families Together

Prevention: A New Strategy for Methamphetamine 11 • Elements of More Effective Prevention • Providing Real Drug Education • Moving Beyond Zero Tolerance • Rejecting Scare Tactics

Treatment is the Answer 14 • Focus on: Increasing Access to Treatment for All Americans • Treatment Works: California’s Proposition 36 • Women and Methamphetamine Policy • Focus on: Supporting Women in Recovery • Gay Men and Methamphetamine • Special Mental Health Issues • Replacement Therapy

Enforcement: A Proper Role for Policing 21

Harm Reduction: Education and Outreach Save Lives 22 Focus on: Optimal Syringe Law Reform

Conclusion 24

Endnotes 25 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 4

Executive Summary

It has been more than 40 years since the first illegal Prevention methamphetamine laboratory was discovered in the United States. The national strategy for dealing with abuse Encouraging people to make healthy choices and providing of this powerful stimulant is the same now as it was then: alternatives to drug use is crucial to reducing substance abuse incarcerate as many methamphetamine law violators as problems. Scare tactics and zero tolerance policies, however, possible and hope for the best. This punitive strategy has often impede prevention efforts. Policymakers can prevent devastated families and public health while failing to make youth methamphetamine abuse by increasing funding for the country safer. There are clear steps, however, that can after-school programs and supporting the development of be taken to reduce methamphetamine abuse and protect a better drug education paradigm that fosters trust and public safety, and places like California, New Mexico, emphasizes factual information over failed scare tactics. Utah, and Vancouver, Canada are leading the way. Adult methamphetamine abuse can be reduced by increasing employment and educational opportunities, strengthening This report lays out the fundamentals of an effective families, and promoting economic growth. Cutting funding national strategy for reducing the problems associated to ineffective programs, such as Drug Abuse Resistance with both methamphetamine misuse and misguided Education (D.A.R.E.), the National Youth Anti-Drug Media U.S. methamphetamine policies. It presents policymakers Campaign, and random student drug testing, would produce with a diverse range of evidence-based policy proposals tremendous savings. that seek to save lives, reduce wasteful government spending, and empower communities. The “four pillars” Treatment of an effective national methamphetamine strategy are prevention, treatment, policing and harm reduction. The quickest, cheapest and most effective way to undermine drug markets and reduce drug abuse is to make quality substance abuse treatment more widely available through public spending, tax credits and other measures. Policymakers should expand access to treatment and mental health services, divert methamphetamine offenders to treatment instead of jail, and promote family unity. More funding should be pro- vided for longer, more intensive methamphetamine treatment, especially in rural areas, with a focus on reducing the significant barriers to treatment that exist for women and gay men. There should also be a greater investment in pharmacotherapy research, including replacement therapy. Policymakers should take every step possible to advance the development of a substitution treatment for methamphetamine abuse, akin to methadone and buprenorphine for opioid addiction.

Policing

Strategic policing is critical to protecting public safety. Law enforcement agencies should concentrate on what only they can do, disrupting and dismantling crime syndicates, appre- hending violent criminals and keeping neighborhoods safe. This requires prioritization in the war on drugs, which means focusing on violent offenders instead of nonviolent drug law violators and on the most problematic drugs instead of the least problematic drugs. Congress should set clear statutory goals for the disruption of major methamphetamine opera- tions, and federal agencies should be required to report on their progress toward these goals, including resources wasted on arresting and prosecuting low-level nonviolent offenders.

2 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 5

Harm Reduction Utah

Investing in harm reduction programs will minimize the Utah recently enacted an innovative program that provides public health threats associated with methamphetamine abuse substance abuse screening and assessment to anyone convicted and reduce healthcare expenditures. Methamphetamine use is of a felony offense (drug- and non-drug-related). The results closely associated with high-risk sexual behavior, which can of these screenings and assessments are provided to the court contribute to the spread of HIV/AIDS and other sexually before sentencing, allowing judges to divert certain offenders transmitted diseases. The sharing of syringes among people to treatment instead of jail. This program, the Drug Offender who use methamphetamine intravenously is also a factor in Reform Act (DORA), is based on a pilot program that has the spread of HIV/AIDS, as well as hepatitis C and other diverted more than 200 offenders in Salt Lake County to infectious diseases. Policymakers should ensure that free treatment instead of jail, many of whom have methamphetamine- condoms and sterile syringes are widely available and increase related problems. The state is also in the process of expanding funding for safe-injection and safe-sex education programs. access to treatment for pregnant and parenting women strug- The federal government should repeal the ban on using federal gling with methamphetamine. The Utah Methamphetamine HIV/AIDS prevention money on syringe exchange programs. Joint Task Force recently rejected calls to develop scare-based TV ads in favor of developing a more realistic and uplifting While the U.S. government has failed to develop an effective prevention campaign. methamphetamine strategy, other governments have implemented successful policies at the state and city level: Vancouver California Vancouver, Canada, leads the world in innovative solutions to the problems posed by methamphetamine production and Although not methamphetamine-specific, California’s abuse. Not only does the city have a well-developed, integrated Substance Abuse and Crime Prevention Act of 2000 four-pillars approach to methamphetamine misuse, it is (Proposition 36) has proven to be the nation’s most systematic developing a replacement therapy program to treat metham- public health response to methamphetamine to date. This phetamine users with legal alternative stimulants such as landmark measure, approved by 61 percent of voters, diverts methylphenidate (Ritalin) and dextroamphetamine. This approximately 35,000 persons from jail to drug treatment program, based on research trials from around the world, every year – over half of whom identify methamphetamine could serve as a model for how to apply successful replace- as their primary illegal drug. No other statewide program ment strategies found effective in treating heroin and nicotine in the nation has offered treatment to or graduated more addiction to methamphetamine and other stimulants. methamphetamine users than Proposition 36. In the process, California taxpayers have saved more than $1.5 billion over Past experience with the cyclical nature of drug abuse the program’s first seven years. outbreaks, as well as an analysis of U.S. and international drug policies, make it clear that local, state and federal gov- New Mexico ernments and the Native American nations should embrace a strong public health response to methamphetamine abuse New Mexico is the only state to have developed a statewide centered on prevention and treatment. Law enforcement methamphetamine strategy that combines prevention, agencies have a very important role to play in this response. treatment, policing and harm reduction. This strategy could Locking up tens of thousands of our fellow citizens, however, become a model for bringing together key stakeholders, is a sign of a failed policy, not a successful one. The problems fostering interagency collaboration, and implementing a associated with methamphetamine are manageable, but only coordinated methamphetamine strategy. In addition, Drug if policymakers take a balanced approach. Policy Alliance New Mexico is working with state agencies and the private sector to implement a youth methampheta- mine education program funded by federal grant money. This campaign will serve as a pragmatic alternative to the failed scare tactics of, most notably, D.A.R.E., the National Youth Anti-Drug Media Campaign, and random student drug testing.

3 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 6

Four-Pillars Policy Checklist Prevention Checklist For a More Effective Eliminate wasteful and counterproductive government prevention programs that rely on scare tactics, such Methamphetamine Policy as D.A.R.E., the National Youth Anti-Drug Media Campaign and random student drug testing. Increase funding for after-school programs and substance abuse treatment. Develop better prevention campaigns based on peer-reviewed research. Support reality-based drug education programs in schools. Eliminate failed zero-tolerance programs in schools and focus scarce resources on professional counseling, intervention and therapy. Increase employment and educational opportunities, strengthen families and promote economic growth.

Treatment Checklist

Make substance abuse treatment more widely available: Divert people convicted of simple methamphetamine possession to drug treatment. Ensure treatment programs are meeting the needs of populations who have faced unique obstacles to effective treatment in the past, such as women, people of color, at-risk youth, lesbian, gay, bisexual and transgendered individuals, and rural populations. Increase funding for replacement therapy research. Make treatment available to all who need it as often as they need it. Allow individuals to deduct the costs associated with substance abuse treatment from their taxes. Eliminate zoning and other regulatory obstacles to opening new treatment centers.

4 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 7

Keep families together: Policing Checklist Increase funding for family treatment programs. Increase funding for treatment programs designed Provide law enforcement officers with better training for pregnant and parenting women. on arresting individuals when children are present to Establish programs that will pay for child care in reduce the emotional damage to children and help areas where no treatment programs exist that parents understand their rights. provide child care services. Focus local and state drug law enforcement on Enact treatment immunity policies that shield parents arresting and prosecuting offenders who commit who seek drug treatment from having their children crimes against people or property by shifting focus taken away. away from nonviolent offenders. Evaluate state and federal prisons on their ability to Re-prioritize federal anti-methamphetamine law transport incarcerated parents to custody hearings. enforcement resources toward drug cartels, and Find ways to increase the ease and quality of family leave low- and medium-level offenders to states. members’ visits to prison; make family caseworkers Set clear statutory goals for the disruption of major available in prison. methamphetamine operations and require agencies Expand re-entry services to help parents returning to report on them. from prison more quickly get their children back into their lives, including expanding housing, employment, education and substance abuse Harm Reduction Checklist treatment services. Eliminate barriers that prevent people from getting Make free condoms more available and increase their lives back together, such as laws that prohibit funding to safe-sex education for high-risk groups. drug offenders from accessing school loans and Make sterile syringes more available and increase public assistance. funding for safer-injection prevention programs. Eliminate programs that stigmatize former offenders, Deregulate the sale of syringes through pharmacies. such as public databases of drug offenders. Decriminalize the possession of syringes. Establish and fund syringe exchange programs. Improve mental health services: Eliminate regulatory and zoning barriers to private Remove barriers separating substance abuse syringe exchange programs. treatment from mental health services. Repeal the federal ban on using HIV/AIDS prevention Fund research examining root causes of money on syringe exchange. methamphetamine abuse and better practices Increase public funding to help clean up clandestine for treating individuals with dual diagnoses. methamphetamine lab sites. Train first responders on how to reduce the harms associated with exposure to methamphetamine operations.

5 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 8

Introduction

A Brief History of Following World War II, during which amphetamine was Methamphetamine in Society widely used to keep combat duty soldiers alert, both amphetamine (Adderall, Benzedrine, Dexidrine) and metham- phetamine (Methedrine, Desoxyn) became more available The history of the use of methamphetamine is intertwined to the public. Amphetamine was used for weight control, with the history of its chemical cousin amphetamine. Their for athletic performance and endurance, for treating mild chemical structures are similar but the effect of methampheta- depression, and to help truckers complete their long hauls mine on the central nervous system is more pronounced. Like without falling asleep. Methamphetamine was widely amphetamine, methamphetamine increases activity, decreases marketed to women for weight loss and to treat depression.5 appetite and causes a general sense of well-being. The initial effects can last up to eight hours, after which there is typically The first instances of clandestine manufacturing of ampheta- a period of high agitation. Consequences of long-term mine and methamphetamine began in 1963, when the methamphetamine abuse can include psychosis, malnutrition, California Attorney General and U.S. Justice Department severe depression and loss of control.1 convinced companies to remove injectable forms of prescription methamphetamine (Benzedrine inhalers and Amphetamine was first synthesized in Germany in 1887.2 liquid methamphetamine in ampoules) from the market.6 Methamphetamine was discovered in Japan in 1919.3 By In 1971, Congress passed the Comprehensive Drug Abuse 1943, both drugs were widely available to treat a range of Prevention and Control Act, which among other things disorders, including narcolepsy, depression, obesity, alcoholism classified amphetamine and methamphetamine as Schedule II and the behavioral syndrome called minimal brain dysfunction drugs, the most restricted category for legal drugs. As a result, (MBD), known today as attention deficit hyperactivity it became much more difficult to legally obtain either drug disorder (ADHD).4 to stay awake, increase productivity, boost stamina, feel better or anything else deemed recreational and not medical. In response to an ever-increasing demand for black market stimulants, their illegal production, especially that of metham- phetamine, increased dramatically.7

Pharmaceutical methamphetamine is still available legally under the brand name Desoxyn, but only infrequently prescribed to treat severe obesity, narcolepsy and ADHD. Pharmaceutical amphetamine is available by prescription under a number of brand names (most notably Adderall) and is commonly prescribed to treat narcolepsy, ADHD, fatigue and (to a much lesser extent) depression.8 Although ostensibly not available to enhance productivity or wakefulness, amphetamine is commonly used that way.9 This has created a divide between those with health insurance who are able to obtain stimulants through legal means and those who seek out black-market stimulants and face arrest.

6 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 9

Facts about Methamphetamine Use

The number of Americans who report binge drinking in the last month – an indicator heavily associated with crime, violence and family dissolution – is more than 90 times the number who report using methamphetamine in the same period. The following official estimates, though not exact, provide a sense of the relative popularity of various drugs and a realistic snapshot of current methamphetamine use rates in the U.S.*

• 10.3 million Americans have tried methamphetamine at least once – far fewer than those who have tried inhalants Moving Beyond a ‘Drug War’ Approach (23 million), hallucinogens (34 million), cocaine (34 million), or marijuana (97 million). While in some ways methamphetamine abuse seems to present • Of those 10.3 million, only 1.3 million used methampheta- new and unique challenges, there are important lessons to mine in the last year; and only 512,000 used it within the be learned from failed efforts to address the abuse of other last 30 days. drugs, such as cocaine and heroin. The bulk of federal efforts • The estimated number of semi-regular methamphetamine to control illegal drugs is comprised of costly – and largely users in the U.S. (those who use once a month or more) unsuccessful – programs to reduce the availability of drugs by equals less than one quarter of one percent of the population attempting to halt their production abroad, interdict them at (0.2 percent). the border, and incarcerate as many (mostly nonviolent) drug • There is no indication that meth use is increasing. The law violators as possible.10 And yet, despite spending hundreds proportion of Americans who use methamphetamine on of billions of dollars and incarcerating millions of Americans, a monthly basis has hovered in the range of 0.2 percent experts acknowledge that illicit drugs remain cheap, potent to 0.3 percent since 1999. and widely available in every community. *Substance Abuse and Mental Health Services Administration. (2006). Results from the 2005 National Survey on Drug Use and Health: National Meanwhile, the harms associated with drug abuse – addiction, Findings (Office of Applied Studies, NSDUH Series H-30, DHHS Publication overdose and the spread of HIV/AIDS and hepatitis – No. SMA 06-4194). Rockville, MD.03. continue to mount, while entire communities are devastated by astronomical incarceration rates. To this record of failure, Crafting an intelligent national methamphetamine response add the extensive collateral damage of drug prohibition and offers the opportunity to make a clean break with the the drug war: broken families, racial inequities, billions of mistakes of the past and embrace a new policy framework wasted tax dollars, and the erosion of hard-fought civil based on reason, compassion and equal justice under the law. liberties. Punitive drug war policies are no more likely to Numerous cost-effective policy options, many developed at succeed in addressing methamphetamine abuse. the state and municipal levels, are already working to reduce rates of addiction, protect public safety and save countless While federal, state and local officials have grappled with lives. An effective national methamphetamine strategy will the issue for more than 40 years, methamphetamine abuse depend on strong leadership, a determination to abandon old continues to present serious and complex threats to health falsehoods about methamphetamine, and the courage to work and public safety. In rural areas, for example, the wide with treatment professionals, community leaders and parents availability of methamphetamine has exacerbated significant to implement evidence-based policies. It is time for a new shortages of resources for drug treatment and infectious bottom line for U.S. drug policy, one that focuses on reducing disease prevention, creating new public health challenges.11 both sets of problems: those associated with drug misuse and As a consequence, the problems typically associated with those stemming from the destructive war on drugs. methamphetamine – crime, environmental contamination, risky sexual behavior and the spread of HIV/AIDS – have jumped to the forefront of national concern.

7 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 10

Introduction

continued from page 7

Perpetuating Old Myths Judging by today’s newspaper headlines, the clandestine Only Makes Matters Worse manufacture, trade and misuse of methamphetamine appears intractable. Reports abound of a national “methidemic.” But Discussions about methamphetamine and related policy in the methamphetamine is among the most infrequently used illegal U.S are often reminiscent of discussions about crack-cocaine drugs, with its use declining among youth, stabilizing among and related policy in the 1980s. Many of the assertions made adults, and demonstrating small decreases in first-time users.14 about crack then – “it’s instantly addictive,” “once you try Only two tenths of one percent of Americans regularly use it you’re hooked for life” – are sometimes made about methamphetamine. Four times as many Americans use cocaine methamphetamine today. Copious amounts of scientific on a regular basis and 30 times as many use marijuana.15 The evidence, however, and numerous studies, including a recent federal government’s own statistics show a clear stabilization analysis by the U.S. Sentencing Commission, show that many of methamphetamine use since 1998, and even declines in of the assertions that elected officials and the media made recent years.16 about crack in the 1980s were not supported by sound data and were exaggerated or outright false.12 Unfortunately, The prevalence of methamphetamine use is higher in selected the punitive crack policies created during this hysteria (most areas, however. Nationwide, just five percent of adult male notably the 100-to-1 crack/powder cocaine sentencing arrestees tested positive for methamphetamine, compared with disparity) are still in place. 30 percent who test positive for cocaine and 44 percent who test positive for marijuana. But in some cities (Los Angeles, Like crack cocaine, methamphetamine poses some serious San Diego and San Jose, California, and Portland, Oregon) public health and law enforcement challenges, but hysteria arrestees tested positive for methamphetamine at a rate of and media hype will once again serve only to impede our 25-37 percent. The Sentencing Project found that in those efforts to address the problem. A culture that perpetuates cities the overall rate of drug use did not rise between 1998 myths about methamphetamine, its use and misuse presents and 2003, suggesting that an increased use of methampheta- a formidable obstacle to progress by biasing the national mine replaced the use of other drugs, particularly cocaine.17 discussion and lowering expectations.13 Any discussion of a truly effective strategy to confront the misuse of methamphetamine requires an honest and straightforward discussion of facts: “I was introduced to • Methamphetamine is not instantly addictive for most people methamphetamines while who use it; and most people who use methamphetamine are serving in the Navy. I used never hooked for life;18 • Far from untreatable, treatment for methamphetamine the drug for over 20 years. addiction is similar to that for cocaine and other stimulants The authorities tried to and just as likely to succeed;19 • The effects of prenatal exposure to methamphetamine are still scare me straight with jail not fully known, but there is no peer-reviewed research that time, but it never worked. demonstrates that prenatal exposure to methamphetamine harms infants; Without [treatment] the • Methamphetamine abuse is neither on the rise nor out of only thing that would control on a national scale, though there are, of course, regional differences.20 have gotten me off of drugs would have been an overdose.” Bill, Los Angeles, CA

8 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 11

Prerequisites for Successful Drug Policy

Supply-side Strategies: their associated environmental dangers. But while much Wasteful and Misguided of the media surrounding methamphetamine focuses on “home cooks” and the need to restrict public access to Drug control strategies that seek to interrupt the supply at pseudoephedrine, approximately 80 percent of the metham- its source have failed over and over again for cocaine, heroin, phetamine consumed in the United States is actually made marijuana and virtually every drug to which they have been beyond our borders.24 Most methamphetamine is smuggled applied – including alcohol during alcohol Prohibition.21 into the U.S. by organized groups of Mexican producers Fundamental economic principles demonstrate why: as long who obtain pseudoephedrine in bulk and mass produce as a strong demand for a drug exists, a supply will be made methamphetamine in “super labs.” available at some price to meet it.22 Worse than simply being ineffective, supply-side strategies drive immutable market The shrinking number of domestic clandestine labs could forces to expand cultivation and trafficking, generate be attributed to Mexican drug cartels working with major unintended consequences and, in many instances, ultimately domestic traffickers to manufacture and import higher worsen the problem. potency methamphetamine. As Florida Attorney General Bill McCollum noted in 2007, “The volume [of methamphet- Methamphetamine is no exception, and an effective national amine] is increasing, it appears to us, and meth in its crystal methamphetamine strategy must therefore depart from past form is still very readily available, maybe even more available approaches to drug control. Previous attempts to curtail in our state today than through the homegrown labs.”25 access to methamphetamine have mostly failed; in some Should authorities successfully crack down on Mexican drug cases, they even backfired. Legislation designed to restrict cartels, other distribution channels are likely to emerge to the availability of legally produced amphetamine and meet the demand. For example, a recent Drug Enforcement methamphetamine, introduced in the 1950s and 60s, had Administration (DEA) report cites the importation of metham- the unintended, though perhaps predictable consequence of phetamine tablets from Southeast Asia through the mail.26 driving the manufacture of methamphetamine to clandestine labs.23 The subsequent proliferation of illegal methampheta- mine labs – which employ highly volatile and toxic chemicals in an unregulated setting – created unique environmental dangers, special job-related hazards for law enforcement, Worse than simply being and new, complex threats to public health and community ineffective, supply-side well being. strategies drive immutable As state and federal enforcement agencies in the 1970s, market forces to expand 80s and 90s implemented precursor restrictions designed to curb access to the chemicals needed to manufacture cultivation and trafficking, methamphetamine, traffickers exploited loopholes, switched generate unintended to new ingredients, bought ingredients in smaller amounts and set up many more – though smaller – illegal labs. consequences and, in many instances, ultimately More recent precursor controls, such as requiring Americans to produce identification and sign a government-mandated worsen the problem. register before purchasing cold and allergy medicines contain- ing pseudoephedrine, may have played a significant role in reducing the number of domestic methamphetamine labs and

9 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 12

Prerequisites for Successful Drug Policy

continued from page 9

Treatment, Not Incarceration, while increasing public safety and saving taxpayers more than Can Keep Families Together one billion dollars through reduced criminal justice expenses. It has also proved to be the nation’s most comprehensive In all their deliberations on our national strategy for metham- public health response to methamphetamine abuse to date.28 phetamine, and other drugs, policymakers should avoid enacting policies that do more harm than good. A policy of Since its inception, 150,000 people have entered drug treatment simply incarcerating low-level drug users, for example, may through Proposition 36, half of whom used methamphetamine create more problems than it solves. Former drug law violators as their primary drug. Many of those entering treatment face countless challenges after completing a jail or prison have long histories (10 or more years) of drug abuse and sentence (the majority of which are for simple possession), Proposition 36 provided them with their first opportunity at including ineligibility to receive public assistance benefits like medically supervised treatment. Proposition 36 data also federal housing, food stamps and student loans, as well as demonstrate that methamphetamine abuse is a treatable tremendous difficulty finding employment. Punitive drug medical condition, with third-year completion rates for policies that rely on incarceration also result in tearing apart methamphetamine (35 percent) comparable to those for families, children being placed into foster care, and the steady cocaine (32 percent) and heroin (29 percent).29 erosion of entire communities. Moreover, incarceration is incredibly expensive, certainly far more so than drug treatment New Mexico, which has long been at the forefront of effective with few long-term societal benefits. public policy on drug-related problems,30 has crafted a statewide methamphetamine strategy based on the four Alternative approaches abound, with California, New Mexico, pillars approach that links prevention, treatment, policing and and several other states leading the way.27 California’s hugely harm reduction. It is a winning model for how policymakers successful drug demand reduction program, the Substance can bring key stakeholders together, foster interagency collab- Abuse and Crime Prevention Act (Proposition 36), allows oration and implement a truly effective methamphetamine first- and second-time nonviolent, simple drug possession strategy. New Mexico’s approach includes leveraging research offenders the opportunity to receive community-based grants to help fund treatment with both traditional and substance abuse treatment instead of incarceration. Approved alternative modalities, increasing access to syringe exchange by 61 percent of California voters in 2000, Proposition 36 and infectious disease testing, reducing criminal activity by has helped tens of thousands of people improve their lives increasing funding for drug treatment, and ensuring that standardized reporting and evaluation tools are used by all prevention agencies to enhance evaluation efforts.31

In formulating a national methamphetamine strategy, policy- makers have an historic opportunity to correct what has been missing from our national approach to drug policy for the last 40 years: a commitment to substance abuse treatment for all who need or seek it. Indeed, better access to treatment options for more Americans may well have prevented the problems associated with methamphetamine abuse currently plaguing many American communities. In lieu of funding for new prisons, a rational methamphetamine strategy would fund treatment services critical to reducing methamphetamine- related problems at their source. The death, disease and disability related to drug abuse can be prevented through closer partnerships between public health and public safety with the larger investment of resources going toward Proposition 36 graduates, 2005 prevention and treatment rather than incarceration. Long Beach, CA

10 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 13

Prevention: A New Strategy for Methamphetamine

Among the world’s most effective drug policies is the four- • Despite D.A.R.E.’s special status as the most widespread pillars approach pioneered in Switzerland and Germany in school-based prevention program in the country, 20 years of the 1990s. A four-pillars drug strategy is a coordinated, studies, including a 2003 U.S. General Accounting Office comprehensive approach that balances public order and evaluation, have consistently concluded that D.A.R.E. has no public health in order to create safer, healthier communities. significant impact on student drug use.36 Moreover, some In Geneva, Zurich, Frankfurt, Sydney and other cities, studies conclude that the program may actually be backfiring, most notably Vancouver, British Columbia, the four-pillars with students becoming even more likely to use drugs the approach has resulted in a dramatic reduction in the number longer they are in the program.37 of users consuming drugs on the street, a significant drop in overdose deaths, and a reduction in the infection rates for • Both U.S. and European studies show that scare tactics, HIV/AIDS and hepatitis.32 the over-use of authority figures, speaking condescendingly to young people, and conveying messages or ideas that A new national strategy on methamphetamine must be as are misleading, extremist or do not conform with young comprehensive and address the four-pillars of any effective people’s own perceptions and experiences – also known as drug policy: prevention, treatment, policing and harm reduction. “manipulative advertising” – are ineffective and may have a counterproductive effect on the target audience.38 Yet, an Elements of More Effective Prevention enormous amount of federal prevention dollars targeting America’s youth are devoted to just such media advertise- The single most effective way for policymakers to prevent ments, though with little progress to show for it. The drug abuse among youth is to increase funding for after-school federal government’s premier youth prevention program, programs. Research shows that most dangerous adolescent the National Youth Anti-Drug Media Campaign, seeks to behavior (including drug use) occurs during the unsupervised reduce youth drug use through television, radio and print ads. hours between the end of the school day and parents’ return Unfortunately, after spending more than $1.5 billion over the home in the evening.33 Increasing funding for after-school last nine years, eight separate government evaluations have programs is especially critical to preventing youth metham- concluded that the ads have had no measurable impact on phetamine abuse in rural areas, where methamphetamine is drug use among youth.39 Two of these studies found the ads heavily concentrated and often where fewer activities are might make some teenagers more likely to start using drugs.40 available. Research shows that students who participate in Additionally, a recent study by researchers at Texas State extracurricular activities are: University at San Marcos found that 18- to 19-year-old college students who viewed the program’s anti-marijuana • less likely to develop substance abuse problems; TV ads developed even more positive attitudes toward • less likely to engage in other dangerous behavior such as marijuana than those who did not.41 violent crime; and • more likely to stay in school, earn higher grades and set and • Student drug testing is the latest costly, scientifically unproven achieve more ambitious educational goals.34 prevention program to gain the federal government’s favor. According to experts in the fields of medicine, adolescent Unfortunately, the federal government continues to waste development, education and substance abuse treatment, hundreds of millions of dollars every year on three failed random, suspicionless drug testing undermines the trust prevention programs: D.A.R.E., the National Youth Anti- between teenagers and adults and deters students who have Drug Media Campaign and student drug testing. Ineffective substance abuse problems from participating in extracurricular at best and counterproductive at worst, lawmakers should activities – the very intervention shown to prevent drug discontinue all three programs,35 and shift existing funding use.42,43 The only national, federally funded, peer-reviewed to after-school programs and substance abuse treatment. study to date compared 94,000 students in almost 900 Ineffective drug prevention messages are a big part of why American schools with and without a drug testing program, prevention efforts are losing ground: and found virtually no difference in illegal drug use.44

The looming public health and safety threats posed by methamphetamine abuse should spur governments at all levels to implement better prevention programs, especially as they pertain to youth (where most prevention resources are already focused). Three key areas for reform stand out.

11 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 14

Prevention: A New Strategy for Methamphetamine

continued from page 11

Providing Real Drug Education Moving Beyond Zero Tolerance

Policymakers should support the development of an education Most American high schools fail to offer either effective drug paradigm for older adolescents, who have matured beyond education or appropriate interventions that would assist the scare tactics intended to inoculate adolescents against students struggling with abuse of alcohol or other drugs. drug use without critical thinking. For older adolescents, an Instead, school-based prevention efforts overly rely upon emphasis on factual information and interactive discussions the threat of the “big four” consequences – exclusion from among peers and credible adults is essential. Research shows extracurricular activities, transfer to another school, suspension that when teens hear what they perceive as lies or half-truths and expulsion – which proponents believe serve as deterrents. from an authority figure they are much less likely to believe Extensive research has shown, however, that these punishments that source in the future.45 Federal programs that attempt to are not likely to change students’ behavior, can potentially convince adolescents that marijuana is as dangerous for them compound the harms associated with drug abuse by isolating as cocaine or methamphetamine, for example, are discrediting students, and that the only factors likely to have a positive themselves and their messages with high school and college- impact on adolescent health-risk behavior are school and age persons. family “connectedness.”47,48 “Zero-tolerance” drug policies that punish students who have problems with drugs instead Young people need and deserve verifiable information about of helping them should be eliminated by schools and replaced drugs, drug chemistry, drug effects, and the relative risks of with a restorative process, in which offenders identify harms different drugs, both legal and illegal. Honest information they caused and make amends (for more information, see de-mythologizes drug use and the romance of transgression www.safety1st.org). A far better prevention strategy than against authority. A good example of an innovative, reality- suspending students with methamphetamine-related problems based drug education and support program for high or otherwise excluding them from an education would be schools is the UpFront program operating in Oakland, CA helping them get access to treatment. (see www.upfrontprograms.org and www.safety1st.org). Although not limited to methamphetamine, UpFront stands Rejecting Scare Tactics in sharp contrast to D.A.R.E. and other failed, scare-based school prevention programs in its ability to create the kind The Office of National Drug Control Policy (ONDCP) has of trusting relationships that will keep teens safe.46 focused only a small part of the National Youth Anti-Drug Media Campaign on methamphetamine prevention (most of the campaign has been focused on marijuana). Some policymakers have urged ONDCP to run more methampheta- mine-related TV ads. But as long as the agency remains wedded to the same outmoded scare-based campaign that The Four-Pillars Drug Strategy has been failing for years, any new methamphetamine ads would likely be just as ineffective, and possibly could do is a coordinated, more harm than good. comprehensive approach Consistent with the federal government’s usual approach that balances public order to drug education, a private venture in Montana has been and public health running scare-based anti-methamphetamine TV ads since 2005.49 The preliminary results are discouraging.50 While in order to create safer, policymakers around the country are understandably anxious healthier communities. to implement media campaigns in their own states, they should be cautious. Most importantly they should invest

12 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 15

“Our job is to create environments where young people talk about what they do … and why they think doing it might or might not be a good idea. It’s not a simple thing and there’s no simple answer.” Chuck Ries, Director, UpFront Program

in research and evaluation and ensure that they are imple- attended by more than 300 teachers, counselors, prevention menting science-based campaigns. If they are interested in specialists, parents and youth. The conference featured innovative approaches that reject scare tactics, they should nationally recognized keynote speakers and interactive break- look at New Mexico and Utah. out sessions that provided current data on methamphetamine use, prevention, treatment, and reality-based approaches to In 2006, the Drug Policy Alliance New Mexico (DPANM) drug education and student assistance programs. The grant is was awarded a grant through the U.S. Department of Justice also being used to fund a social marketing campaign created to create a statewide methamphetamine prevention and by and for youth, including a prevention video and discussion education project directed at high-school-age youth. Working guide that is currently in production. The final phase of the with a statewide advisory committee comprised of representa- grant will fund training and technical assistance to communi- tives from state health agencies, local prevention programs ties statewide to build prevention capacity and enhance and community-based coalitions, DPANM is focusing on effective substance abuse prevention and education programs promoting science-based information and youth engagement, for our youth. rather than simplistic “Just Say No” messages. The grant funded a two-day statewide conference entitled Building In Utah, the Utah Methamphetamine Joint Task Force rejected Positive Communities: A Public Health Approach to Teen a proposed Montana-like scare-based media campaign in favor Methamphetamine Prevention in October 2007, which was of a more realistic and nuanced one. Instead of commercials featuring “ghoulish faces that demonize meth users,” the Utah media campaign will emphasize that recovery is possible and that people have it in them to improve their lives.51

13 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 16

Treatment is the Answer

At least 20 recent studies show the efficacy of methampheta- • California’s CALDATA study found that every dollar mine treatment, despite the persistence of myths to the invested in alcohol and drug treatment saved taxpayers contrary.52 A 2003 survey of various treatment approaches more than seven dollars, due to reductions in crime and published in the Journal of Substance Abuse Treatment healthcare costs.58 concluded, “Clients who report methamphetamine abuse • Oregon estimates its return on every dollar invested in respond favorably to existing treatment.”53 A Washington treatment to be $5.62, primarily in the areas of corrections, State study found “there were no statistically significant health and welfare spending.59 differences across a series of outcomes between clients using • A Substance Abuse and Mental Health Services methamphetamine and those using other substances.”54 Administration (SAMHSA) study found that treatment Treatment success rates and relapse rates for methamphetamine reduces drug selling by 78 percent, shoplifting by almost are similar to those for other drugs, with no documented 82 percent and assaults by 78 percent. Treatment decreases differences among male and female users.55 arrests for any crime by 64 percent. After only one year, use of welfare declined by 10.7 percent, while employment In 2005, an open letter to the media signed by 92 prominent increased by 18.7 percent. Medical visits related to substance physicians, treatment specialists and researchers warned, abuse decreased by more than half following treatment, “Claims that methamphetamine users are virtually untreatable while in-patient mental health visits decreased by more than with small recovery rates lack foundation in medical research,” 25 percent.60 and noted that such erroneous claims were causing great harm. The open letter continues, “Analysis of dropout, Implementing prohibitionist policies without providing and retention in treatment and re-incarceration rates and other funding treatment options poses its own special problems. measures of outcome, in several recent studies indicate that A three-state, $6.1 million study conducted in counties in methamphetamine users respond in an equivalent manner as Arkansas, Kentucky and Ohio raises concerns that laws individuals admitted for other drug abuse problems.”56 intended to drive down the manufacture and use of metham- phetamine in rural areas may actually be causing unwanted Moreover, dozens of scientific studies to date have shown side effects by driving up the use of cocaine. The two-year that increased funding for treatment is absolutely the most study, funded by the National Institute on Drug Abuse and cost-effective way to undermine drug markets and reduce published in a 2008 issue of the journal Addiction, noted a drug abuse. The evidence of the effectiveness of treatment is statistically significant increase in cocaine use of nine percent overwhelming: associated with the implementation of laws designed to reduce methamphetamine use although, due to the study’s • A RAND Corporation study for the U.S. Army and the observational design, the authors caution against making Drug Czar’s office found treatment to be 10 times more definitive conclusions. effective at reducing drug abuse than drug interdiction, 15 times more effective than domestic law enforcement, and This and studies like it underscore the importance of making 23 times more effective than trying to eradicate drugs at their a broad spectrum of treatment services available to the public. source. It concluded that for every dollar invested in drug Simply instituting restrictions on precursor ingredients, such treatment taxpayers save an estimated $7.46 in social costs. as over-the-counter cold medicines, will not decrease overall In contrast, taxpayers lose 85 cents for every dollar spent substance abuse. Treatment on demand – not incarceration – on source-country control, 68 cents for every dollar spent on is the surest way to ensure that well-intended policy measures interdiction, and 48 cents for every dollar spent on domestic do not merely exchange one set of societal problems for law enforcement.57 another.

14 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 17

Increasing Access to Treatment for All Americans

Policymakers at all levels of government 1) Increase federal, state and local funding to provide treatment for more people. Treatment should include should ensure that substance abuse mental health services, as well as sexual abuse, domestic treatment is available to all who need it, abuse and child abuse services to deal with the root causes of addictive behavior. Treatment options should whenever they need it, and as often as strive for inclusion and offer both abstinence-based and they need it. Unfortunately, as many as ten non-abstinence-based treatment. Policymakers should also ensure that treatment programs are meeting the million Americans each year do not receive needs of populations that have faced unique hurdles to the substance abuse treatment for alcohol accessing substance abuse treatment in the past, such as women, people of color, youth, lesbian, gay, bisexual and * and other drugs that they need. transgendered individuals, and rural populations.

2) Provide people in need of treatment with vouchers Of the ways to expand access to redeemable for treatment services through the program treatment, four stand out: of their choice. The Bush administration has already established a model program, Access to Recovery, which provides block grants to states for distributing treatment vouchers to those who need it. Congress should fully fund this program, and states should take advantage of it and supplement it with their own funds where needed. The City of Milwaukee has operated its own treatment voucher program for a decade and could serve as a model.

3) Increase the number of people who can access substance abuse treatment through their health insurance. This would require expanding access to health insurance in general, encouraging more companies to include substance abuse and mental health treatment in the insurance policies they offer their employees, and requiring insurance companies to reimburse their customers for treatment expenses at the same level as other medical expenses (known as “parity”).

4) Provide tax credits to people who pay for substance abuse treatment for themselves or others.

* U.S. Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration, “Changing the Conversation: Improving Substance Abuse Treatment: The National Treatment Plan Initiative; Panel Reports, Public Hearings, and Participant Acknowledgements” (Washington, D.C.: SAMHSA, November 2000), p. 6.

15 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 18

Treatment is the Answer

continued from page 15

Treatment Works: Women and Methamphetamine Policy

California’s Proposition 36 It is especially important that policymakers devote more California is leading the way in providing comprehensive resources to tailored treatment services for women, especially treatment to reduce methamphetamine abuse and its associated pregnant and parenting women. In contrast to other problems. The Substance Abuse and Crime Prevention Act of illicit drugs, rates of admission to treatment for methamphet- 2000 – also known as Proposition 36 – sponsored by a Drug amine are roughly equal for women (47 percent) and men Policy Alliance affiliate and approved by California voters, (53 percent).63,64 Women also face unique obstacles to requires the state to provide drug treatment, rather than jail recovery, ranging from being the primary caretaker of their time, for nonviolent drug possession offenders. While not children to having been physically, emotionally or sexually specific to methamphetamine offenders, more than 19,000 abused. Yet, a 2004 U.S. government study found that only methamphetamine users enter treatment annually under this 32 percent of treatment facilities in the U.S. have unique program, and no other program in the nation has offered programs for women, while only 14 percent have special treatment to or graduated more methamphetamine users. programs for pregnant or postpartum women.65

A recent evaluation by the University of California Los While no national data are currently available on child Angeles (UCLA) found that California taxpayers saved nearly welfare cases specifically attributed to methamphetamine, $2.50 for every dollar invested in the program. Of people some state and county agencies have reported increases in the who successfully completed their drug treatment, California number of children separated from their families because of taxpayers saved nearly $4 for each dollar spent. In all, parental use of methamphetamine.66 Unfortunately, less than Proposition 36 is estimated to have saved state and local eight percent of all U.S. treatment programs provide childcare, government more than $1.3 billion over its first six years.61 and only five percent provide residential beds for children.67 Yet almost two thirds of all individuals seeking treatment for Other states to implement treatment-instead-of-incarceration methamphetamine are believed to have minor children.68 programs in recent years include Maryland, Texas and Utah, Women with children cannot enroll in in-house treatment although none as comprehensive as California’s Proposition 36. programs unless accommodations exist for their dependent children. Mothers needing outpatient treatment services While Proposition 36 is unquestionably a model for how to may have difficulty being on time or making every meeting – effectively address the methamphetamine problem, it does not problems arise with their children and they need to balance go far enough. People with substance abuse problems should work and family with treatment. not have to get arrested to receive effective drug treatment. It is both cheaper for taxpayers and better for public safety to In a 2005 survey of 13 states, 40 percent of child welfare provide quality treatment to those who need it before they officials reported an increase in out-of-home placements in encounter the criminal justice system. An estimated 300,000 the last year due to methamphetamine use.69 While it may be Americans who sought treatment in 2005 for the abuse of warranted to remove children from a parent who is violent, alcohol or other drugs did not receive it. The most commonly dysfunctional or clearly unable to fulfill their parental respon- cited reason for failure to obtain treatment was cost.62 sibilities, the removal of a child, placement in foster care and adoption all have significant drawbacks as well. Too often children are removed based solely upon a parent’s drug use. Policymakers should strive to preserve family unity to the extent possible.

16 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 19

Women who use methamphetamine and bear children have Supporting Women in Recovery: increasingly become the targets of state prosecutors seeking to prosecute them for “fetal” abuse and delivery of drugs • Nearly 15 percent of women who use methamphetamine are through the umbilical cord.70 Advocates for women and single parents, more than four times the percentage of men.i children universally agree that women should engage in behaviors that promote the birth of healthy children. • More than 40 percent of women who use methamphetamine However, they also recognize the complex factors inherent to are unemployed compared to about 10 percent of men.ii substance abuse must be met with constructive responses.71 • Women who seek treatment for methamphetamine on aver- According to the American Medical Association, “Pregnant age use methamphetamine with greater frequency than men.iii women will be likely to avoid seeking prenatal or other medical care for fear that their physician’s knowledge of • Women in treatment for methamphetamine have higher substance abuse … could result in a jail sentence rather than instances of psych ological trauma, physical trauma, and both proper treatment.”72 The effects of prenatal exposure to long and short-term sexual abuse. Women are more than four methamphetamine are still unknown. “In utero physiologic times as likely to have been sexually abused in the 30 days dependence on opiates (not addiction), known as Neonatal immediately prior to entering treatment.iv Narcotic Abstinence Syndrome, is readily diagnosable and treatable, but no such symptoms have been found to occur • Approximately 37 percent of women who use methampheta- following prenatal cocaine or methamphetamine exposure.”73 mine in California say that they use the drug to lose weight, compared to nine percent of men; an equal number of men Drug use during pregnancy is a health issue that requires and women use it to relieve depression.v appropriate care from qualified health professionals, not destructive interventions by law enforcement. Every major • Young girls represent almost 70 percent of treatment medical and public health organization in the country admissions for methamphetamine among 12- to opposes the arrest and jailing of pregnant women for the use 14-year-olds, and more than half of treatment admissions of alcohol, methamphetamine or other drugs.74 Policymakers for 15- to 17-year-olds.VI should stress treatment over incarceration when it comes to women who use methamphetamine or other drugs during i The CSAT Methamphetamine Treatment Project: A Comparison of pregnancy. Characteristics of Men and Women Participants at Baseline, slide 6. ii Ibid (slide 7). iiiIbid (slide 9). iv Yih-Ing Hser, Elizabeth Evans, Yu-Chuang Huang, “Treatment outcomes among women and men methamphetamine abusers in California,” Journal of Substance Abuse Treatment 28, no. 1, page 84. v Ibid (table 3, page 82). vi Ibid (page 2).

Proposition 36 Rally, 2008 Sacramento, CA

17 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 20

Treatment is the Answer

continued from page 17

Gay Men and Methamphetamine The GLMA recommends increasing the cultural competency of substance abuse clinicians, conducting more research on Gay men also face a shortage of prevention and treatment the social and sexual context of methamphetamine use, and programs tailored to their needs. A November 2006 report developing more effective treatment programs (including by the Gay and Lesbian Medical Association (GLMA), pharmacological approaches).78 “Breaking the Grip: Treating Crystal Methamphetamine Addiction Among Gay and Bisexual Men,” draws upon several Special Mental Health Issues studies to estimate that 10-20 percent of gay men in major cities have used methamphetamine in the past six months.75 Additional funding for research that examines the root causes The report notes that, “Psychosocial pressures – including of methamphetamine abuse, including whether methampheta- homophobia, discrimination, fear, loss and stigma resulting mine offenders are self-medicating for depression, Attention from HIV/AIDS, and a public discourse which denigrates the Deficit Disorder or other disorders would help lay a foundation ‘lifestyle choices’ of [lesbian, gay, bisexual and transgendered] for new treatment modalities. A key component of such persons, same-sex marriage, and equal rights – often result in studies should be what role the lack of access to healthcare internalized homophobia, feelings of low self worth and generally, and prescription drugs specifically, plays in perpetu- depression, and these conditions increase susceptibility to ating methamphetamine abuse. drug addiction in some individuals. Gay men frequently use methamphetamine to cope with anxiety, depression, loneliness In general, policymakers should facilitate better collaboration and fears about being physically unattractive due to aging.”76 between mental health programs and substance abuse programs. Although 80-90 percent of mental disorders Yet, effective treatment programs for gay men are are treatable using medication and other therapies, only severely lacking: 50 percent of adults who need help receive it.79 In many cases, mental health agencies will not treat someone who is Even in major urban areas with large gay populations and abusing drugs, while substance abuse agencies cannot treat established general healthcare programs serving them, the person until their mental health issues are resolved. there is still a significant lack of culturally appropriate This bureaucratic Catch-22 situation prevents many drug substance abuse programs for gay men. Substance abuse offenders from getting the help they need. Lack of health treatment professionals in other cities and rural areas, have insurance or inadequate coverage may drive some people little understanding of the clinical needs of gay men or to treat medical conditions with black market drugs. knowledge of resources to provide treatment. When dealing with methamphetamine dependence among gay men, it is important that healthcare providers are able to discuss frankly with their patients and clients the situations and motivations surrounding their methamphetamine use. In After receiving treatment many, if not most instances, these situations and motiva- tions will include past and/or present sexual activity. Focus through a prison diversion group members provided numerous anecdotes about program, Mary Pruitt went patients who reported previous experiences in addiction treatment programs where staff [was] unwilling to discuss back to school in the field such issues, and core triggers in their addictions were never of recovery, received her addressed during the treatment. This suboptimal treatment results in poor clinical outcomes, alienates patients who certification and has been feel that their needs are not being met, and wastes finan- working in a women’s cial resources of government and private insurance funds that pay for treatment that demonstrates poor efficacy.77 recovery house in Sacramento since 2003.

18 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 21

Replacement Therapy In 1998, Australian and New Zealand researchers found positive results in the use of dextroamphetamine to treat Like alcohol and other drugs it is important for policymakers intravenous amphetamine users. Seventy percent of the to invest in research for viable replacement therapy options patients who were prescribed dextroamphetamine in pill for methamphetamine abuse. Under replacement therapy, form decreased their intravenous use of illegal street ampheta- doctors prescribe one or more pharmaceutical drugs to mine.85 In contrast, 67 percent of intravenous heroin users people with substance abuse problems to eliminate or reduce who were prescribed methadone decreased their heroin use.86 their use of problematic drugs and improve their mental and Similarly, researchers in the United Kingdom are extremely physical well-being. The exact therapy differs from drug to confident in the use of dextroamphetamine to treat stimulant drug and patient to patient. In some cases the therapy is abuse. In a 2001 study, researchers found that prescribing direct, such as prescribing medications that block or limit the dextroamphetamine decreased their clients’ consumption effects of the drug the patient is abusing (e.g., Naltrexone for of street methamphetamine and amphetamine and reduced opiates.) In other cases the therapy is indirect, such as pre- the frequency of intravenous drug use.87 Other studies have scribing medication to treat problems that might be driving reached similar conclusions.88 their drug use (treating depression with Prozac or Attention Deficit Disorder with Ritalin). Sometimes doctors prescribe The United Kingdom’s Department of Health recommends patients an alternative to the drug they are abusing that is the limited prescription of dextroamphetamine to patients longer lasting but less euphoric (such as methadone and who use street amphetamine in order to reduce craving, buprenorphine for heroin users). And sometimes doctors minimalize withdrawal, and stabilize them as part of drug prescribe an alternative form of the drug a patient is abusing treatment.89 It is not uncommon for British doctors to that is safer and less problematic (the “patch” for cigarette prescribe dextroamphetamine to amphetamine abusers on smokers and pharmaceutical-grade heroin for heroin users). an ongoing basis to reduce criminality and legal problems, discourage injection drug use and improve the health of their Research into pharmacotherapies for the treatment of stimu- patients.90 lants has fallen into two areas: antagonists that block the abused drugs’ effects thus precluding or reducing use; and Unfortunately, many studies on the use of dextroamphetamine agonists that partially replace effects of the abused drug, to treat stimulant abuse have been limited by their small thereby stabilizing the patient. Because stimulants affect mul- sample sizes and lack of controlled randomization. More tiple neurotransmitter systems both antagonists and agonists studies are needed, especially in the United States. must interfere with the action of a number of systems to be effective, making the development of an effective medication A federally-funded report prepared for the National Institute challenging. So far no medication has been approved as of Justice, a division of the U.S. Justice Department, concluded: uniquely effective for treatment of methamphetamine abuse or dependence in the United States.80 Poor results with [antagonist] drugs have encouraged a further look at the use of replacement or agonist therapies Antagonist strategies have traditionally not shown much in the treatment of amphetamine/methamphetamine abuse, success in treating stimulant abuse.81 The use of agonists, much like the approach used with methadone in the treat- however, to treat stimulant abuse (including methampheta- ment of opioid abuse. As with methadone, the approach mine) has shown promise. Currently, there are two stimulant relies in part on a harm reduction model in that it replaces drugs that are praised globally in research for replacement the illicit drug, methamphetamine, with a legal, controlled therapy for stimulant abuse: dextroamphetamine82 and dose of a stimulant or replacement drug provided, however, modafinil.83 A 2004 comprehensive review of the available in a therapeutic setting together with supportive services research on stimulant replacement therapies concluded that can be supplied. The replacement of, for example, dex- oral dextroamphetamine may help stabilize illicit ampheta- troamphetamine for methamphetamine would ideally mine users’ dependency and provide some reduction in the reduce problems related to crime, injection practices, family use of other drugs, injection behavior and criminal activity.84 and economic issues, and health problems related to escalating illegal use. Grabowski and colleagues (2003) have reviewed the available and somewhat limited research on using replacement (agonist) therapies in the

19 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 22

Treatment is the Answer

continued from page 19

treatment of methamphetamine or amphetamine abuse. notes that, “Because modafinil has shown early efficacy in These studies are often small and involve self selected cocaine treatment and may have positive effects on executive samples and self reporting of behavior changes. However, function and impulsivity, it is being tested as a potential many indicate that using oral dextroamphetamine to treatment in methamphetamine addiction.”94 stabilize illicit amphetamine users’ dependency can provide some reduction in the use of other drugs, injection behavior The city of Vancouver, Canada, is working to implement the and criminal activity.91 first stimulant replacement program in North America. Under the plan, called Chronic Addiction Substitution Treatment Modafinil (marketed under the name “Provigil”) is a mild (CAST), up to 700 chronic cocaine and methamphetamine non-amphetamine stimulant originally approved as a medica- users would be provided with replacement medication, such tion for narcolepsy. It is increasingly used to ward off fatigue as Ritalin or dextroamphetamine. The program, which would and increase concentration and alertness in both the military need an exemption from Canada’s drug laws from the federal and the private sector. Numerous studies have confirmed that government, is part of an ambitious city program to cut its use does not cause elation or euphoria like amphetamine homelessness, panhandling and drug dealing in half by 2010.95 and methamphetamine, making it an unlikely drug to be abused.92 In fact, the DEA has classified it as a Schedule IV The United States lags behind Canada and Europe in allowing drug because it has a “low potential for abuse.” Early studies doctors to prescribe medication to treat substance abuse suggest that it is helpful in the management of psychostimulant problems. U.S. policymakers should increase funding for the withdrawal symptoms such as hypersomnia, poor concentra- study of both agonists and antagonists to treat methampheta- tion and low mood. Case reports point to positive responses mine abuse. Doctors should be able to use dextroamphet- in both cocaine- and amphetamine-dependent patients with maine, modafinil and other medications to treat stimulant no apparent over-stimulation or abuse.93 addiction as part of counseling and drug treatment, if it is deemed medically warranted, in the same way that methadone Although the use of modafinil in treating methamphetamine and buprenorphine are used to treat opiate addiction. People abuse is still in the early stages of research, Nora Volkow, struggling with substance abuse problems should have a M.D., the director of the National Institute on Drug Abuse diverse array of treatment options.

“I started using alcohol and drugs when I was 12. I had been in and out of state and federal prison throughout my life for nonviolent drug offenses and was never before offered treatment. In prison there were more drugs in a smaller area. I was worn out and struggling with crank when I entered Proposition 36. I switched to a more intensive residential treatment program and felt like I was finally offered the tools I needed to make a change.” Scott, Sacramento, CA

20 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 23

Enforcement: A Proper Role for Policing

Law enforcement agencies have been required to play an • Re-prioritize scarce law enforcement resources. This means unrealistic role in our nation’s drug policies for far too long, refocusing enforcement on those who pose the greatest and have been unfairly blamed for their failure to grapple threat to others and on the most dangerous drugs. Violent with social problems largely beyond their control. For methamphetamine sellers should take enforcement priority instance, because treatment, prevention and other public over nonviolent marijuana sellers. Shutting down major health strategies have not received adequate funding, the methamphetamine crime syndicates should take precedence brunt of addressing methamphetamine and its associated over incarcerating people simply for methamphetamine use. harms has fallen on the shoulders of state and local law enforcement. Instead of being the last line of defense, law A recent publication by the American Enterprise Institute enforcement has become the first – and in some cases only – summarizes this last point succinctly: response to methamphetamine-related problems. This has strained policing budgets and put law enforcement officers [I]t is hard to find evidence that the sharp ratcheting-up in perpetual danger. of [drug arrests] since the late 1980s has done much to reduce availability or increase price. At the same time, Ultimately, policymakers must begin to treat drug abuse as however, there has been some good news about enforce- a healthcare issue that has an important criminal justice ment, which is that carefully crafted policing strategies can component. Implementing a comprehensive approach to materially reduce drug-related crime and violence and the methamphetamine provides a good opportunity to do so. blight of open drug markets. An effective policing strategy for methamphetamine and other illegal drugs would: Clearly, retail-level drug enforcement should focus on what it can accomplish (reducing the negative side effects of • Concentrate law enforcement resources on drug law offenders illicit markets) and not on what it can’t achieve (substantially who threaten public safety – people who commit violence, raising drug prices). Thus, instead of aiming to arrest drug steal to support their habit, or drive while impaired. People dealers and seize drugs – the mechanisms by which who are not harming others should be left to private and enforcement seeks to raise prices – retail drug enforcement public health agencies to deal with. Since many drug law should target individual dealers and organizations that violators cause no harm to others, law enforcement could engage in flagrant dealing, violence, and the recruitment of easily improve public safety with existing resources by juveniles. Arrests and seizures should not be operational shifting the public health burden to appropriate public goals, but rather tools employed, with restraint, in the health agencies. service of public safety.100 • Refrain from doing anything that exacerbates the harms associated with drug abuse, such as arresting people enrolled Local and state anti-methamphetamine law enforcement in syringe exchange programs – especially those that local resources should focus on apprehending violent methamphet- authorities have legalized and encouraged96,97 – or arresting amine sellers or users who commit crimes against people drug users who call 911 when a companion is overdosing. or property, and disrupting criminal networks. Federal anti- One study of nearly 400 current or former drug users in methamphetamine resources should focus on large cases that Baltimore, Maryland, who reported having witnessed a drug cross international and state boundaries, with a priority on overdose, found that just 23 percent of the participants disrupting Mexican drug cartels and major domestic crime reported calling an ambulance to report the overdose.98 To syndicates. Low- and medium-level offenses should be left the greatest extent possible, law enforcement should build to state criminal justice systems. Congress should set clear partnerships with the public, helping drug users find public statutory goals for the disruption of major methamphetamine health services and seeking their help in protecting public operations, and federal agencies should be required to report safety.99 on their progress toward these goals, including resources wasted on low-level drug offenses.

21 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 24

Harm Reduction: Education and Outreach Save Lives

Harm reduction (sometimes called risk minimization) is a Increasing the availability of sterile syringes through syringe public health strategy designed to reduce the harms of activi- exchange programs, pharmacies and other outlets reduces ties that cannot be completely eliminated. It is often used as a unsafe injection practices such as syringe sharing, curtails fall-back strategy when prevention efforts fail. For example, transmission of HIV/AIDS and hepatitis, increases safe one of the best known examples of a drug-related harm disposal of used syringes, and helps intravenous drug users reduction strategy is when parents instruct their teenagers to obtain drug education and treatment. Every established call home if they are ever intoxicated or stranded and need a medical and scientific body that studied the issue concurs on ride home, no questions asked. Other examples include pro- the efficacy of improved access to sterile syringes toward viding cigarette smokers with safer nicotine delivery devices reducing the spread of infectious diseases, including: (such as nicotine patches) or making sterile syringes available to injection drug users to reduce the spread of HIV/AIDS and • National Academy of Sciences; other infectious diseases. Harm reduction strategies in other • American Medical Association; areas include safe sex education, seat belt laws and amnesty • American Public Health Association; and laws that encourage desperate mothers to drop their babies • Centers for Disease Control and Prevention. off at hospitals and churches rather than abandoning them. Seven government reports conclude access to sterile syringes While there are many harm reduction strategies that could does not increase drug use. No report yet exists that contra- mitigate problems associated with methamphetamine abuse, dicts this basic finding.103 the most urgent need is to address related public health threats. As noted above, methamphetamine use is of particular The consequences of failing to make sterile syringes more concern among the gay male community. Among gay men widely available are dire. According to the U.S. Centers for methamphetamine is closely associated with high-risk sexual Disease Control and Prevention (CDC), of the 415,193 persons behavior, which can spread HIV/AIDS and other sexually reported to be living with AIDS in the U.S. at the end of transmitted diseases. For instance, a 2003 study of gay and 2004, at least 30 percent of cases were related to injection bisexual men who used methamphetamine, found that more drug use.104 About 12,000 Americans contract HIV/AIDS than half had engaged in high risk sexual behaviors such as directly or indirectly from the sharing of dirty syringes each unprotected sex, or having sex with someone who had HIV year.105 About 17,000 contract hepatitis C.106 An estimated or later developed HIV.101 While little research has been one in seven stimulant users (amphetamine and methamphet- devoted to studying the association between methamphetamine amine) report injection drug use in their lifetime.107 A recent use and sexual risk among heterosexuals, what research has study found that rural methamphetamine users are more likely been conducted suggests prolonged use of the drug signifi- to inject the drug than urban users.108 The strong presence of cantly increases high-risk sexual behavior.102 In addition to methamphetamine in rural areas, combined with the significant culturally appropriate drug and safe-sex education, the shortage of both drug treatment and HIV/AIDS prevention widespread availability of free condoms is essential to prevent resources in those areas, make the sharing of dirty needles a HIV infections and reduce government healthcare expenditures. serious threat to public health.109 The lifetime cost of treating just one person with HIV can be as high as $600,000.110 Sharing of syringes among people who use methamphetamine intravenously is also a factor in the spread of HIV/AIDS, as Finally, policymakers should continue to adopt measures to well as hepatitis C and other infectious diseases. Policymakers reduce the harms associated with the illegal production of at all levels should make sterile syringes widely available, and methamphetamine. Recent precursor controls may have increase funding for safe-injection education programs. The reduced some of the public health threats posed by domestic federal government should repeal the ban on using federal methamphetamine labs (although as previously noted, with HIV/AIDS prevention money on syringe exchange programs. some negative consequences); but more should be done. In particular, the federal government should increase funding to states for the safe clean-up of methamphetamine lab sites. Local and state governments should provide better training to law enforcement officers, first responders, child service workers and anyone else who could become exposed to dangerous methamphetamine precursors through the course of their work.

22 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 25

Optimal Syringe Law Reform

Depending on existing law in a particular i Lurie P, Reingold A. The Public Health Impact of Needle Exchange Programs in the United States and Abroad (prepared for the Centers for Disease Control state, optimal syringe law reform may and Prevention). Berkeley, CA: University of California, School of Public Health, and San Francisco, CA: University of California, Institute for Health require one or more of the following: Policy Studies; 1993:68. Ganz A, Byrne C, Jackson P. Role of community pharmacies in prevention of AIDS among injecting drug misusers: findings of a survey in England and Wales. British Medical Journal. 1989;299: 1076- • Deregulate the sale of sterile syringes, so that pharmacies 1079. Bless R, et al. Urban Policies in Europe 1993. Amsterdam: Amsterdam can sell them to customers without a prescription. Bureau of Social Research and Statistics; 1993. Pharmacy sale is standard throughout most U.S. states, ii Vlahov D. Deregulation of the sale and possession of syringes for HIV pre- Western Europe, much of Central and Eastern Europe, and vention among injection drug users. Journal of Acquired Immune Deficiency Oceania.i Syndromes and Human Retrovirology. 1995; 10:71; Editorial. Valleroy L, Weinstein B, Jones TS, Groseclose SL, Rolfs RT, Kassler, WJ. Impact of increased legal access to needles and syringes on community pharmacies: • Eliminate criminal penalties for possession of syringes, needle and syringe sales – Connecticut, 1992-1993. Journal of Acquired so that people who use drugs intravenously can carry Immune Deficiency Syndromes and Human Retrovirology.1995; 10:73-81. sterile syringes and properly dispose of used ones. (After iii Hurley SF. Effectiveness of needle-exchange programmes for prevention of Connecticut changed its paraphernalia and prescription HIV infection. Lancet 1997;349:1797. Survey included primarily U.S. cities laws in 1992 to allow for possession and sale of up to ten and found that cities with syringe exchange programs had an 11 percent lower rate of increase in seroprevalence each year. syringes, needle sharing dropped 40 percent and needle stick injuries to police decreased 66 percent.)ii

• Remove all legal barriers to syringe exchange programs and increase public funding to such programs. A worldwide survey found that HIV seroprevalence among intravenous drug users decreased 5.8 percent per year in cities with needle exchange programs, and increased 5.9 percent per year in cities without syringe exchange programs.iii

23 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 26

Conclusion

While methamphetamine abuse and the proliferation of • Severe consequences can result from ignoring public health illegal methamphetamine labs have recently become subjects and human rights concerns. If policymakers had prioritized of heightened national concern, state and federal policymakers making drug treatment available to all who needed it in the have been grappling with both problems for more than 1980s, instead of arresting millions of Americans for what 40 years. During this time, policymakers have enacted one they put into their own bodies, they may very well have ineffective policy after another. This is one reason why prevented many of the methamphetamine-related problems the problems associated with methamphetamine – crime, that plague our country now. Additionally, making sterile addiction, child neglect, the spread of HIV/AIDS – continue syringes widely available would have saved tens of thousands to mount. An effective national strategy for addressing of American lives. methamphetamine abuse is possible but it will take real leadership to pass and enact. Implementing an effective national methamphetamine strategy would provide policymakers with an opportunity to break Policymakers must take the lead in stopping the perpetuation from the mistakes of the past. They could adopt a new drug of myths. Methamphetamine is not instantly addictive. policy framework based on treatment instead of jail, strategic People who use it are not hooked for life. Methamphetamine policing and harm reduction. Ideally, and obviously, this new addiction is never untreatable. These and other myths perme- framework should apply to all illegal drugs, not just metham- ate the national methamphetamine discussion and give rise to phetamine. Its essential policies should include: both defeatism and hysteria. The problems associated with methamphetamine abuse are serious, but they are manageable. • providing treatment to all who need it, whenever they need it, and as often as they need it; • Policymakers should also learn from the mistakes of the past: • developing reality-based prevention programs that foster trust Our country cannot incarcerate its way out of the metham- and emphasize factual information; phetamine problem. Punitive policies have been exhaustively • investing in pharmacotherapy, including replacement therapy, tried and they have failed, not just with methamphetamine, and expanding treatment options; but also with cocaine, heroin, marijuana and numerous • making sterile syringes more widely available to reduce the other drugs (including alcohol). Despite spending hundreds spread of HIV/AIDS and other infectious disease; of billions of dollars and incarcerating millions of Americans, • prioritizing family unity; and illegal drugs remain cheap, potent and widely available in • shifting enforcement resources away from incarcerating every community. low-level nonviolent drug law violators toward disrupting • Many drug policies do more harm than good. Breaking up and dismantling violent crime networks. families perpetuates drug abuse, poverty and crime. Prohibiting former drug offenders from receiving public Methamphetamine poses many challenges to policymakers, assistance, housing, school loans and other benefits makes but there is no need for panic. There are clear steps elected it even harder for them to put their lives back together. officials can take to reduce methamphetamine abuse, protect Aggressively arresting and incarcerating people who use public safety, eliminate government waste and save lives. drugs increases drug-related deaths because people are afraid These steps – some small, some large – would improve the to call 911 when their friends are overdosing. Using scare lives of hundreds of thousands of Americans, and states like tactics and over-the-top messages in prevention campaigns California and New Mexico are already leading the way. can cause people to rebel against prevention messages, undermining prevention efforts.

24 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 27

Endnotes

1 National Institute on Drug Abuse. “Methamphetamine Abuse and 18 Surveys show that most people who use methamphetamine never Addiction.” NIDA Research Report Sept. 2006: NIH Publication become regular users. See United States. Substance Abuse and No. 06-4210. National Institute on Drug Abuse. 2006. National Mental Health Services Administration. Results from the 2005 Institutes of Health, Bethesda, MD. . NSDUH Series H-30, DHHS Publication No. SMA 06-4194. 2 “Owen, Frank. No Speed Limit: The Highs and Lows of Meth. New Rockville, MD: Office of Applied Studies, 2006. York, NY: St. Martin’s Press, 2007. 19 King, Ryan. The Next Big Thing? Methamphetamine in the United 3 Ibid. States. Washington, D.C.: The Sentencing Project, Jun. 2006; and 4 Ibid; National Institute of Justice. “Methamphetamine Use: Lessons Otero, Cathleen, and Sharon Boles, Nancy K. Young, Dennis Kim. Learned.” Cambridge, MA: Abt Associates Inc. Contract No. 99-C- Methamphetamine Addiction, Treatment, and Outcomes: 008.31, Jan. 2006. Implications for Child Welfare Workers. Irvine, CA: National Center 5 Ibid; National Institute of Justice. “Methamphetamine Use: Lessons on Substance Abuse and Child Welfare, April 2006: 12-13. Learned.” Cambridge, MA: Abt Associates Inc. Contract No. 99-C- 20 Ibid. 008.31, Jan. 2006. 21 Boyum, David, and Peter Reuter. An Analytic Assessment of U.S. 6 National Institute of Justice. “Methamphetamine Use: Lessons Drug Policy. Washington, D.C.: American Enterprise Institute Press, Learned.” Cambridge, MA: Abt Associates Inc. Contract No. 99-C- 2005; Reuter, Peter. “The Limits of Supply-Side Drug Control.” The 008.31, Jan. 2006. Milken Institute Review Santa Monica, CA, First Quarter 2001: 15- 7 Ibid. 23; and Youngers, Coletta, and Eileen Rosin, Ed. “Drugs and 8 National Institute on Drug Abuse. “Methamphetamine Abuse and Democracy in Latin America: The Impact of U.S. Policy.” Addiction.” NIDA Research Report Sept. 2006: NIH Publication Washington Office on Latin America Special Report Washington, No. 06-4210. National Institute on Drug Abuse. Reprinted January D.C., Nov. 2004: 1-5. 2002. Revised September 2006. National Institutes of Health, 22 Reuter, Peter. “The Limits of Supply-Side Drug Control.” The Milken Bethesda, MD. . 23 Owen, Frank. No Speed Limit: The Highs and Lows of Meth. New 9 McCabe, Esteban, and John Knight, Christian Teter, Henry Wechsler. York, NY: St. Martin’s Press, 2007; National Institute of Justice. “Non-medical Use of Prescription Stimulants among U.S. College “Methamphetamine Use: Lessons Learned.” Cambridge, MA: Abt Students: Prevalence and Correlates from a National Survey.” Associates Inc. Contract No. 99-C-008.31, Jan. 2006. Addiction 100.1 (Jan. 2005): 96-106; and Teter, Christian, and 24 Tandy, Karen. “Statement by Administrator Karen P. Tandy on Two Esteban McCabe, James Carnford, Carol Boyd, Sallie Guthrie. Hundred and Seven Million in Drug Money Seized in Mexico City.” “Prevalence and Motives for Illicit Use of Prescription Stimulants in 2007. Drug Enforcement Administration. 20 Mar. 2007 an Undergraduate Student Sample.” Journal of American College . Health 53.6 (May-Jun. 2005). 25 Associated Press. “Attorneys general say meth labs pushed offshore, 10 Boyum, David, and Peter Reuter, An Analytic Assessment of U.S. smuggled in.” Associated Press 12 April 2007. Drug Policy, Washington, D.C.: American Enterprise Institute Press, 26 Drug Enforcement Administration. “State Factsheets.” Washington, 2005; and Reuter, Peter. “The Limits of Supply-Side Drug Control,” D.C. 30 May 2008 The Milken Institute Review (First Quarter 2001): 15-23. . 11 Kraman, Pilar. “Drug Abuse in America – Rural Meth,” Trends 27 Drug Policy Alliance. State of the States. Drug Policy Reforms: Alert. Lexington, KY: The Council of State Governments, Mar. 1996-2002. New York, NY: Drug Policy Alliance, Sep. 2003. 2004. 28 University of California Los Angeles. Evaluation of the Substance 12 United States. Sentencing Commission. Report to Congress: Cocaine Abuse and Crime Prevention Act: Final Report. Los Angeles, CA: and Federal Sentencing Project. Washington, D.C.: GPO, May 2007. UCLA Press, 13 April 2007; Drug Policy Alliance. Proposition 36: 13 King, Ryan. The Next Big Thing? Methamphetamine in the United Looking Back and Beyond. New York, NY: Drug Policy Alliance, Jun. States. Washington, D.C.: The Sentencing Project, Jun. 2006. 2003; and Drug Policy Alliance. Proposition 36: Improving Lives, 14 Ibid; and United States. Substance Abuse and Mental Health Delivering Results. New York, NY: Drug Policy Alliance, Mar. 2006. Services Administration. Results from the 2005 National Survey on 29 Ibid. Drug Use and Health: National Findings. NSDUH Series H-30, 30 Drug Policy Alliance. State of the States. Drug Policy Reforms: DHHS Publication No. SMA 06-4194. Rockville, MD: Office of 1996-2002. New York, NY: Drug Policy Alliance, Sep. 2003. Applied Studies, 2006. 31 New Mexico Methamphetamine Working Group. 2005 Statewide 15 King, Ryan. The Next Big Thing? Methamphetamine in the United Strategy Recommendations: A Comprehensive Plan for New Mexico States. Washington, D.C.: The Sentencing Project, Jun. 2006. Communities. Santa Fe, NM: New Mexico Methamphetamine 16 United States. Substance Abuse and Mental Health Services Working Group, Sep. 2005 . Use and Health: National Findings. NSDUH Series H-30, DHHS 32 “Four Pillars Drug Strategy.” City of Vancouver. 28 Sept 2007. Publication No. SMA 06-4194. Rockville, MD: Office of Applied . Studies, 2006. 33 United States. Department of Education and Department of Justice. 17 King, Ryan. The Next Big Thing? Methamphetamine in the United ‘Safe and Smart’: Making After-School Hours Work for Kids. States. Washington, D.C.: The Sentencing Project, Jun. 2006. Washington, D.C.: GPO, 1998.

25 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 28

Endnotes

continued from page 25

34 Willits, Glancy and Farrell, P. “Adolescent Activities and Adult 50 An initial evaluation of the Montana media campaign found that Success and Happiness: Twenty-four years later,” Sociology and the percentage of young people viewing methamphetamine use as Social Research 70.3, 1986: 242. risky behavior actually declined during the campaign. A subsequent 35 While funding for D.A.R.E. and student drug testing has remained evaluation found that teen methamphetamine use remained relatively relatively stable over the last few years, Congress has significantly stable during the ad campaign, suggesting it had little to no impact cut funding to the National Youth Anti-Drug Media Campaign, on methamphetamine use rates. More recently, the Montana Meth cutting it from $100 million in FY2007 to $60 million in FY2008. Project has claimed that their media campaign has led to a decrease 36 United States. General Accounting Office. “Youth Illicit Drug Use in the number of first-time methamphetamine users in Montana. Prevention: DARE Long-Term Evaluations and Federal Efforts to This claim, however, is based on an independent survey that did not Identify Effective Programs.” Memo GAO-03-172R to Hon. Richard measure the effectiveness of their ad campaign; thus it is impossible J. Durbin, U.S. Senate, Washington, D.C. 15 Jan. 2003: 2. to determine what impact if any the media campaign had on this 37 Rosenbaum, Dennis, and Gordon Hanson. “Assessing the Effects of statewide trend. The survey also only looked at first-time meth use School-Based Drug Education: A Six-Year Multi-Level Analysis of and not regular use. Additionally, while the survey found that first- Project D.A.R.E.” Journal of Research in Crime and Delinquency time methamphetamine use rates were declining among Montana 35.4, 1998: 381-412. high school students, it found that first-time methamphetamine use 38 Hastings, Gerard, and Martine Stead, John Webb. “Fear Appeals in rates were increasing among middle school students. In any event, Social Marketing: Strategies and Ethical Reasons for Concern,” first-time methamphetamine use rates among both groups were Psychology and Marketing 21.11, Nov. 2004: 961-986. declining in the years preceding the launch of the advertising 39 Hornik, Robert, et al. Evaluation of the National Youth Anti-Drug campaign. See: Montana Meth Project. “Montana Meth: Use and Media Campaign. Rockville, MD: Westat, Attitudes Survey.” Apr. 2006, Montana Meth Project, 28 Sep. 2007 Jul. 2000, Nov. 2000, Apr. 2001, Oct. 2001, May 2002, Jan. 2003, ; Montana Office of Public Instruction. 2007 Montana 40 United States. Government Accountability Office. “ONDCP Media Youth Risk Behavior Survey Sep. 2007 ; and Fenske, Sarah. “For $5 million Arizona can grow its Youth Anti-Drug Media Campaign was Effective in Reducing Youth population of meth users – just like Montana.” Phoenix New Times. Drug Use,” Report GAO-06-818, Washington, D.C., Aug. 2006: 42. April 26, 2006. 41 Czyzewska, Maria, and Harvey J. Ginsburg. “Explicit and implicit 51 Brenton, Ana. “TV spots offer meth addicts hope: New approach effects of anti-marijuana and anti-tobacco TV advertisement,” differs from ‘ghoulish’ spots that demonized users, which were Addictive Behaviors 32.1, Jan. 2007: 114-127. rejected.” The Salt Lake Tribune. 15 May 2007. 42 American Academy of Pediatrics, et al. Brief of Amici Curiae, 52 King, Ryan S., “The Next Big Thing? Methamphetamine in the “Board of Education of Independent School District No. 92 of United States,” The Sentencing Project: Washington, D.C., Jun. 2006. Pottawatomie County, et al. v. Lindsay Earls, et al.” 536 U.S. 822 53 Cretzmeyer, M., and M.V. Sarrazin, D.L. Huber, et al. “Treatment of (2002) (No. 01-332), 30 May 2008 Methamphetamine Abuse: Research Findings and Clinical Directions.” . Journal of Substance Abuse Treatment, 24 (2003): 267-277. 43 Taylor, Robert. “Compensating Behavior and the Drug Testing of 54 Luchansky, B. “Treatment for Methamphetamine Dependency is as High School Athletes.” The Cato Journal 16.3, Winter 1997. Effective as Treatment for Any Other Drug.” Olympia, WA: Looking 44 Yamaguchi, Ryoko, and Lloyd D. Johnston, Patrick M. O’Malley. Glass Analytics, 2003. “Relationship Between Student Illicit Drug Use and School Drug- 55 Otero, Cathleen, and Sharon Boles, Nancy K. Young, Dennis Kim, Testing Policies,” Journal of School Health. 73. 4, 2003: 159-164 “Methamphetamine Addiction, Treatment, and Outcomes: . Implications for Child Welfare Workers.” Irvine, CA: National 45 Beck, Jerome. “100 Years of ‘Just Say No’ Versus ‘Just Say Yes’: Center on Substance Abuse and Child Welfare, April 2006: 12-13. Reevaluating Drug Education Goals for the Coming Century,” 56 David C. Lewis MD. “Meth Science Not Stigma: Open Letter to the Center for Educational Research and Development: Evaluation Media,” Brown University, 25 Jul. 2005 . 46 Through a series of dialogue-driven, interactive workshops, 57 Rydell, and Evering. Controlling Cocaine. Washington, D.C.: Rand combined with group and individual work, UpFront provides a Corporation, 1994. forum for discussion while conveying age-appropriate prevention 58 California Department of Alcohol and Drug Programs. Evaluating messages. Created primarily based on students’ feedback, this Recovery Services: The California Drug and Alcohol Treatment multi-tiered program can be tailored to the specific needs of both Assessment. Chicago, IL: National Opinion Research Center, 2004. students and the school. 59 National Center on Addiction and Substance Abuse at Columbia 47 Taylor, Robert. “Compensating Behavior and the Drug Testing of University. “Shoveling Up: The Impact of Substance Abuse on State High School Athletes,” The Cato Journal 16. 3, Winter 1997. Budgets.” New York, NY: CASA Jan. 2001. 48 Resnick PhD, Michael, and Peter S. Bearman PhD, et al. “Protecting 60 Substance Abuse and Mental Health Services Administration. Adolescents from Harm: Findings from the National Longitudinal National Treatment Improvement Evaluation Study. Washington, Study on Adolescent Health.” Journal of the American Medical D.C.: GPO, 1996. Association 278.10, 10 Sep. 1997: 823-832. 61 University of California Los Angeles. Evaluation of the Substance 49 Beginning in 2005, the Meth Project became Montana’s largest Abuse and Crime Prevention Act: Final Report. Los Angeles, CA: advertiser . UCLA Press, 13 April 2007.

26 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:19 AM Page 29

62 Substance Abuse and Mental Health Services Administration. 84 Grabowski, John, and Shearer, Merrill, Negus. “Agonist-like Results from the 2005 National Survey on Drug Use and Health: replacement pharmacotherapy for stimulant abuse and dependence,” National Findings. Rockville, MD: Office of Applied Studies, Addictive Behaviors, 29, 2004: 1439-1464. NSDUH Series H-30, DHHS Publication No. SMA 06-4194, 2006. 85 Charnaud, B., and V. Griffiths. “Levels of intravenous drug misuse 63 Generations United. Meth and Child Welfare: Promising Solutions among clients prescribed oral dexamphetamine substitution for for Children, Their Parents and Grandparents. Washington, D.C.: amphetamine dependence.” Addiction 96.9, 2001:1286-96. Generations United, 2006: 10. 86 Ibid. 64 Brecht, Mary-Lynn, and Ann O’Brien, Christina von Mayrhauser, M. 87 Klee, Hillary, and Samantha Wright, Tom Carnwath, John Merrill. Douglas Anglin. “Methamphetamine use behaviors and gender dif- “The Role of Substitute Therapy in the Treatment of Problem ferences.” Addictive Behaviors 29, 2004: 90. Amphetamine Use.” Drug and Alcohol Review 20.4, 2001: 417-429. 65 United States. Office of Applied Studies. National Survey of 88 Ibid; Shearer, James, and John Sherman, Alex Wodak, Ingrid Van Substance Abuse Treatment Services (N-SSATS). 2006, Substance Beek. “Substitution Therapy for Amphetamine Users.” Drug and Abuse and Mental Health Services Administration, July 2008 Alcohol Review 21, 2002: 179-185; Myton, Tracey, and Tom . Carnwath, Llana Crome. “Health and Psychosocial Consequences 66 Generations United. Meth and Child Welfare: Promising Solutions Associated with Long-Term Prescription of Dexamphetamine to for Children, Their Parents and Grandparents. Washington, D.C.: Amphetamine Misusers in Wolverhampton (UK) 1985-1998.” Generations United, 2006: 9. Drugs: Education, Prevention, and Policy 11.2, April 2004; McBride, 67 Ibid. A.J., G. Sullivan, A.E. Blewett, S. Morgan. “Amphetamine 68 Ibid. Prescribing as a Harm Reduction Measure: A Preliminary Study.” 69 National Association of Counties. The Meth Epidemic in America: Addiction Research 5, 1997: 95-111; Fleming, P.M., and D. Roberts. Two Surveys of U.S. Counties; The Criminal Effect of Meth on “Is the Prescription of Amphetamine Justified as a Harm Reduction Communities; The Impact of Meth on Children. Washington, D.C.: Measure?” Journal of the Royal Society for the Promotion of Health National Association of Counties, 5 Jul. 2005. 114, 1994:127-131; Shearer, J., and A. Wodak, R.P. Mattick, I.V. 70 Center for Reproductive Rights. Punishing Women for their Beek, J. Lewis. “Pilot Randomized Controlled Study of Behavior During Pregnancy: An Approach the Undermines Women’s Dexamphetamine Substitution for Amphetamine Dependence.” Health and Children’s Interests. New York, NY: Center for Addiction. 96, 2003: 1289-1296; Sherman, J.P. “Dexamphetamine Reproductive Rights, Sep. 2000: 1. for ‘Speed’ Addiction.” The Medical Journal of Australia. 153, 1990: 71 Ibid: 8. 306; Alexander, B.K., and J.Y. Tsou. “Prospects for Stimulant 72 American Medical Association. “Board of Trustees Report: Legal Maintenance in Vancouver, Canada.” Addiction Research and Interventions During Pregnancy.” Journal of the American Medical Theory 9, 2001: 97-132. Association 264, 1990: 2663-2667. 89 Northern Ireland. United Kingdom. Drug Misuse and Dependence – 73 Lewis MD, David C., “Meth Science Not Stigma: Open Letter to the Guidelines on Clinical Management. Department of Health, Scottish Media,” Brown University, 25 Jul. 2005. Office. Department of Health, Welsh Office. Department of Health 74 Center for Reproductive Rights. Punishing Women for their and Social Services of Northern Ireland. 1999. Behavior During Pregnancy: An Approach the Undermines Women’s 90 Ibid.; Moselh, H.F., and A. Georgiou, Kahn, E. Day. “A Survey of Health and Children’s Interests. New York, NY: Center for Amphetamine Prescribing by Drug Services in the East and West Reproductive Rights, Sep. 2000: 1-8. Midlands.” Psychiatric Bulletin 26, 2002: 61-62; Strang, J., and J. 75 Gay and Lesbian Medical Association. Breaking the Grip: Treating Sheridan. “Prescribing Amphetamines to Drug Misusers: Data from Crystal Methamphetamine Addiction Among Gay and Bisexual the 1995 National Survey of Community Pharmacies in England Men. San Francisco, CA: Gay and Lesbian Medical Association, and Wales.” Addiction 92, 1997: 833-838; Bruce, M. “Managing Nov. 2006: ii. Amphetamine Dependence.” Advances in Psychiatric Treatment 6, 76 Ibid: 1. 2000: 33-40. 77 Ibid: 24. 91 National Institute of Justice. Methamphetamine Use: Lessons 78 Ibid: 26. Learned. Bethesda, MD: Abt Associates Inc. Contract No. 99-C-008, 79 United States. Centers for Disease Control and Prevention. 31 Jan. 2006. “Eliminate Disparities in Mental Health.” Centers for Disease 92 Malcom, Robert, et al. “Clinical Applications of Modafinil in Control and Prevention. 30 May 2008, . Addictions 11,2002: 247-249. 80 De Lima, M.S., and B. Oliveira-Soares, A.A. Reisser, M. Farell. 93 Shearer, James; and Linda Gowing. “Phramacotherapies for prob- “Pharmacological treatment of cocaine dependence: A systematic lematic psychostimulant use: a review of current research.” Drug review.” Addiction 97.8, 2002: 931-949. and Alcohol Review 23, Jun. 2004: 203-211; Hart, et al. “Smoked 81 Ibid. Cocaine Self-Administration is Decreased by Modafinil.” 82 Shearer, J., and J. Sherman, A. Wodak, I. van Beek. “Substitution Neuropsychopharmacology 2007:1-8; Camacho, A., and M.B. Stein. therapy for amphetamine users.” Drug Alcohol Review 21, 2002: “Modafinil for social phobia and amphetamine dependence.” 179-185. American Journal of Psychiatry 159, 2002: 1947-8; Dackis, 83 Dackis, C., and C. O’Brien. “Glutamateric agents for cocaine Malcolm. “Medications Development Research for Treatment of dependence.” Annals of New York Academy of Sciences, 1003, Amphetamine and Methamphetamine Addiction – Report to 2003: 328-345. Congress.” Washington, D.C.: National Institute on Drug Abuse, Aug. 2005.

27 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:23 AM Page 30

Endnotes

continued from page 27

94 Volkow, Nora. “Availability and Effectiveness of Programs to Treat 103 The seven reports are: National Commission on AIDS. The Twin Methamphetamine Abuse.” Statement from the Director of the Epidemics of Substance Abuse and HIV. Washington, D.C.: National National Institute on Drug Abuse, National Institutes of Health, Commission on AIDS, 1991; United States. General Accounting U.S. Department of Health and Human Services. Testimony before Office. Needle Exchange Programs: Research Suggests Promise as an the Subcommittee on Criminal Justice, Drug Policy, and Human AIDS Prevention Strategy. Washington, D.C.: GPO, 1993; Lurie, P., Resources, Committee on Government Reform, United States House and A.L. Reingold, et al. The Public Health Impact of Needle of Representatives. 28 Jun. 2006. Exchange Programs in the United States and Abroad. San Francisco, 95 Join Together. “Vancouver Mayor Touts Drug Maintenance CA: University of California Press, 1993; Satcher MD, David. Letter Programs,” 23 Jan. 2007 Join Together, 30 May 2008 to Jo Ivey Bouffard: The Clinton Administration’s Internal Reviews . Disease Control and Prevention, 10 Dec. 1993; Normand, J., and D. 96 Human Rights Watch. “Injecting Reason: Human Rights and HIV Vlahov, L. Moses (eds.). Preventing HIV Transmission: The Role of Prevention for Injection Drug Users-California: A Case Study.” Sterile Needles and Bleach. Washington, D.C.: National Academy New York, NY: Human Rights Watch, 15.2(G), Sep. 2003: 22. Press, National Research Council and National Institute of 97 Davis, Corey S., and Scott Burris, Julie Kraut-Becher, Kevin G. Medicine, 1995: 224-226, 248-250; United States. Office of Lynch, David Metzger. “Effects of an Intensive Street-Level Police Technology Assessment of the U.S. Congress. The Effectiveness of Intervention on Syringe Exchange Program Use in Philadelphia, Pa.” AIDS Prevention Efforts. Springfield, VA: National Technology American Journal of Public Health 95, 2 Feb. 2005: 233-236. Information Service, 1995; National Institutes of Health Consensus 98 Tobin, Karin E., and Melissa A. Davey, Carl A. Latkin. “Calling Panel. Interventions to Prevent HIV Risk Behaviors. Kensington, emergency medical services during drug overdose: an examination MD: National Institutes of Health Consensus Program Information of individual, social and setting correlates.” Addiction 100.3, Center, Feb. 1997. Also see: Paone, D., and D.C. Des Jarlais, R. Mar. 2005: 397. Gangloff, J. Milliken, S.R. Friedman. “Syringe Exchange: HIV pre- 99 In 2006, Drug Policy Alliance New Mexico wrote vention, key findings, and future directions.” International Journal of and backed a “911 Good Samaritan” bill, which Gov. Richardson the Addictions 30, 1995: 1647-1683; Watters, J.K., and M.J. Estilo, signed into law in April 2007, the first such law in the country. This G.L. Clark, J. Lorvick. “Syringe and Needle Exchange as HIV/AIDS unique law will save thousands of lives by protecting people from Prevention for Injection Drug Users.” Journal of the American arrest when they call 911 in response to a drug overdose. The Medical Association 271, 1994: 15-120. chance of surviving an overdose, like that of surviving a heart 104 United States. Centers for Disease Control and Prevention. attack, depends greatly on how fast one receives medical assistance. HIV/AIDS Surveillance Report 2004 Vol. 16, 2005: 20 (Table 10). No one thinks twice about calling 911 when they witness a heart 105 United States. Centers for Disease Control and Prevention. attack, but people who witness an overdose often hesitate to call lest Drug-Associated HIV Transmission Continues in the United States. they be arrested on drug law violations or other charges. Washington, D.C.: Centers for Disease Control and Prevention, 100 Boyum, David, and Peter Reuter. An Analytic Assessment of U.S. May 2002. Drug Policy. Washington, D.C.: American Enterprise Institute Press, 106 United States. Centers for Disease Control and Prevention. 2005: 95. Viral Hepatitis and Injection Drug User. Washington, D.C.: 101 Cretzmeyer, et al, “Treatment of methamphetamine abuse: research Centers for Disease Control and Prevention, Sep. 2002. findings and clinical directions.” Journal of Substance Abuse 107 Li-Tzy ScD, Wu, and Daniel J. Pilowsky MD, Wendee M. Wechsberg Treatment 24, 2003: 267-277. PhD, William E. Schlenger PhD. “Injection Drug Use Among 102 Semple, Shirley J., and Thomas L. Patterson, Igor Grant. “The con- Stimulant Users in a National Sample.” American Journal of Drug text of sexual risk behavior among heterosexual methamphetamine and Alcohol Abuse 30. 1, 2004: 61-83. users.” Addictive Behaviors 29, 2004: 807-810. 108 Ross, Timberly. “Study: Meth addicts in rural areas face more health problems.” Associated Press. 25 Apr. 2007. 109 Ibid. A recent Nebraska-funded study found that rural addicts began using meth at a younger age, were more likely to use the drug intravenously and to be dependent on alcohol or cigarettes. They also exhibited more signs of psychosis than urban addicts, 45 percent vs. 29 percent, according to the study. 110 Schackman, B. “The Lifetime Cost of Current Human Immunodeficiency Virus Care in the United States.” Medical Care 44, Nov. 2006: 990-997.

28 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:23 AM Page 31

About the Drug Policy Alliance

The Drug Policy Alliance (DPA) is the nation’s leading About the Author organization promoting alternatives to the drug war Bill Piper is director of national affairs for the that are grounded in science, compassion, health and Drug Policy Alliance, where he lobbies Congress in human rights. It is headquartered in New York and support of a “new bottom line” for U.S. drug policy; has offices in California, New Jersey, New Mexico and one that seeks to reduce the negative consequences Washington, D.C. associated with both drugs and the war on drugs. He has more than 12 years of Washington, D.C. DPA Network (our partner organization) was responsi- political experience and writes and speaks often ble for drafting and building broad public support for on methamphetamine-related issues. California’s Substance Abuse and Crime Prevention Act of 2000 (Proposition 36), which has become the Acknowledgements nation’s most systematic public health response to The author would like to especially thank Derek Hodel methamphetamine abuse to date. In 2005, the and Isaac Skelton for providing enormous help Drug Policy Alliance’s New Mexico office assembled writing, rewriting and editing this report. Ken Collins, stakeholders from around the state to form the New Grant Smith and Jasmine Tyler provided essential Mexico Methamphetamine Working Group, co-chaired research, along with Albert Cahn, Hilary Kimball, by the governor’s drug czar and the director of DPA Kristen Millnick, Julia Laskorunsky and Kelsey Nunez. New Mexico. In 2007, DPA New Mexico received a A large number of people provided crucial advice, grant from the U.S. Justice Department to create ideas and feedback, including Luciano Colonna, Carl a statewide methamphetamine education and Hart, Ethan Nadelmann, Roseanne Scotti and Reena prevention program directed at New Mexico high Szczepanski. This report was significantly influenced school students. DPA’s Washington, D.C. office has by the work of Glenn Backes and Mary Taft-McPhee. helped shape numerous methamphetamine-related federal laws.

DPA Office of National Affairs Contact Bill Piper Director, Office of National Affairs [email protected] 202.683.2985 voice

Media Contact Tony Newman Director, Media Relations [email protected] 212.613.8026 voice 626.335.5384 mobile 2901_Meth_Report_for_final_PDF.qxd:Layout 1 8/7/08 10:23 AM Page 32

Drug Policy Alliance Office of National Affairs 925 15th Street, NW 2nd floor Washington, D.C. 20005

202.683.2030 voice 202.216.0803 fax [email protected]

Drug Policy Alliance Headquarters 70 West 36th Street 16th floor New York, NY 10018

212.613.8020 voice 212.613.8021 fax [email protected]

www.drugpolicy.org

6 7