"Just come out. I know you're there!"
Micki Preston could not understand why her brother was not worried about the strangers she was spotting around her home in the Navajo community of Chinle, Arizona.
Her family was actually more worried about her. Then in her twenties, she was "strung out," hallucinating and reeling from days of binging on methamphetamine.
More recently, in New York City, another addict pondered his infatuation with "Tina" -- a term of endearment for the fine white powder that has ignited the gay club scene -- during a 72-hour streak of raging insomnia.
In rambling reflections posted to Tweaker.org, the web forum of San Francisco's methamphetamine resource center Stonewall Project, the user wrote: "When I look in the mirror, I behold a face looking back at itself in horror and exhaustion and guilt and shame." But then he ticked off Tina's virtues: "the sex, the confidence, the invincibility, the yearning and the uninhibitedness."
Tina is catching everyone's eye. As police across the country attempt to squelch the supply of the drug, two vastly different communities - America's Heartland and the urban gay scene - are trying new ways of coping with the ups and downs of "meth."
Among young gay men, meth is known as a designer drug that induces euphoric sex. In working-class rural communities, it provides a cheap, homebrewed high.
Also known as "crystal" and "poor man's cocaine," the powerful stimulant is smoked, snorted, injected or ingested. Effects range from heightened alertness to violent behavior. Meth abuse can lead to health problems including long-term brain damage and heart failure, and research has linked increased HIV transmission to the high-risk sexual activity that often accompanies the drug's influence.
Meth is relatively affordable, as hard drugs go - about $100 can get several people high for hours. It is also accessible -internationally trafficked and home-cooked in simple labs. These factors led to a rapid growth in meth use in the 1990s, though government surveys indicate that nationwide usage stabilized between 2002 and 2004. According to federal data, roughly 5 percent of people aged 12 or older have experimented with meth, placing its popularity somewhere between crack and inhalants.
With its wide prevalence and unique demography, meth is defying drug war convention and stimulating dialogue -- as well as controversy -- over drug policy reform.
From The Reservation To The Dance Floor
In the drug war arena, reform groups like the Harm Reduction Coalition and Drug Policy Alliance are pushing what they see as a more balanced alternative to hardline jail-or-abstinence drug strategies. While acknowledging that drugs cannot be eliminated, they say the damaging effects can be limited through regulation, education and common sense.
"In a perfect world, it would be nice if we could just make everybody stop doing everything bad," said Doug McVay, director of research with the California-based advocacy organization Common Sense for Drug Policy. "But it ain't a perfect world."
So-called "harm reduction" strategies aim for positive change, not perfection. They range from needle exchange programs for intravenous drug users to awareness campaigns and therapy techniques that inform users but do not preach abstinence.
Research suggests that such approaches may help reduce health damage tied to substance abuse. One evaluation of harm reduction policy in Australia estimated that public investment in needle exchange programs helped prevent about 25,000 AIDS cases and 21,000 Hepatitis C cases during the 1990s. A study on an HIV/AIDS outreach program in Denver, Colorado during the 1990s revealed that among a group of 890 intravenous drug users who received health counseling, rates of both condom use and needle disinfection rose significantly over a two-and-a-half-year period, while both practices decreased in a separate control group.
Proponents of non-punitive, health-focused drug policies say that contact between meth users and the health system is inevitable; the question is whether intervention occurs in a treatment center or an emergency room.
In the late 1990s, Thomas Drewhard, a general surgeon in the predominantly Navajo community of Tuba City, Arizona, started to notice strange trends in the local emergency room intakes: stab and gunshot wounds from unusually violent outbreaks, seventeen year-olds with heart trouble, and people in various states of drug-induced psychosis.
"We didn't know that meth was here at that time," he said. But after talking to community members, he learned that kids on the reservation were being introduced to the drug as "a fairly innocuous thing" -- an upper that worked "like five cups of coffee."
By 2003, it was clear that meth was spreading more rapidly than knowledge about the drug's effects. "I decided that we had to get to every single kid before the school let out that spring," Drewhard recalled. He worked with community leaders to develop a public education campaign, with Navajo-language presentations, and eventually helped push through a formal ban against meth on the reservation.
Even with the prohibition, however, Navajo meth policy remains rooted in promoting awareness, not punishment.
Lynette Willie, spokesperson for the Navajo Department of Behavioral Health Services, said that with limited resources to serve a population of more than 200,000, a policy focused on building community rather than isolating addicts makes sense from a clinical and a logistical standpoint. Currently, reservation communities develop individual task forces, which independently coordinate outreach campaigns.
The question is whether intervention occurs in a treatment center or an emergency room. When users interact with behavioral health staff, Willie said, the aim is not to impose any particular program but rather to empower users to devise their own coping strategies. An addict "may not decide to change whatsoever," she said, but behavioral health specialists work to "stabilize" the situation, helping families and users understand the nature of addiction. "If that person did want treatment," she said, "then we would go and assist the family in doing that."
Like other native substance abuse programs, the Navajo Nation's approach to meth draws on aspects of indigenous culture, encouraging users to seek support from traditional clan networks, and to use spiritual healers for ritual purification.
"Being culturally consistent, working on restoring balance, and dealing with wholeness is the essence of the treatment," said Charles Stacey, a treatment specialist with the Navajo Nation's Indian Health Services.
Clients at the Totah Recovery Center in Farmington, New Mexico - many of them homeless Navajos - are not pressured to quit immediately; the staff prioritizes helping clients stabilize and reconnect with their communities.
Still, Totah's primary goal is to enable clients to live drug-free. "I see harm reduction as a way of engaging people as part of that path to recovery," said Paul Ehrlich, a treatment specialist at the center.
Ehrlich observed that among meth users in treatment, "we do see very positive recovery rates, if it's focused well and if it's long enough." But he noted that instead of concentrating on statistical recovery rates, it is more vital for service providers, on an individual level, "to believe in people who are very, very sick and can get well and do well."
Though the rustic rhythms of the Navajo Nation seem distant from the frenetic pulse of the urban gay scene, harm reduction programs have also helped illuminate meth's dangers in the drug-laced "male-to-male" underground.
In San Francisco, where a 2005 study found that HIV infection rates among meth users are about triple the rate among those who don't use meth, the Stonewall Project offers just the facts. In counseling clients, plastering sex clubs with informational ads, and operating its online clearinghouse, Tweaker.org, Stonewall does not moralize about meth, but instead helps people use more safely.
"We tell them how it's done, but we also tell them why it's risky," said Kevin Mosley, a Stonewall counselor and coordinator of Tweaker. Alongside Tweaker's slick graphics and exultations of Tina's exhilarating effects, readers find advice about needle exchange and negotiating condom use with partners. The underlying message, he said, is "if you're going to continue to use, you might find X, Y and Z happening in your brain, in your body, in your life, with your family."
Of more than 50 participants discharged from Stonewall's client-directed treatment program in the 2003-2004 fiscal year, nearly 90 percent stayed with the Project for more than two months. About 70 percent completed treatment goals, were referred to other programs, or left with self-reported satisfactory progress.
Stonewall's non-judgmental harm-reduction framework provides users with a full array of options, from maintaining a certain level of meth use to quitting completely. But most decide, on their own, to kick the habit.
When Preston's family discovered that meth was unraveling her brain, they wanted her out -- and gave her two places to go.
"I didn't want to go to the hospital, and I didn't want to go to jail, but those were my choices," she recalled. "So, I went to the hospital."
But Preston's path to recovery, which would stretch through the 1990s, was not exactly of her own choosing. The doctor sent her home with some valium to calm down. It was only when she took the whole bottle at once that she landed in a long-term treatment facility -- typically a rare opportunity in poor native communities.
"That's a horrible way to have to try to get into rehab, you know," said Preston, who has been clean for about six years. "It should be available when somebody's ready, and they ask to go."
To critics, conventional drug policy is doubly misguided. It not only misses the people who need and seek rehabilitation; it also hits users with criminal penalties that are potentially more damaging than the drug itself.
According to a 2005 report from the National Association of Counties (NACo), over 80 percent of 500 surveyed counties lack readily accessible treatment facilities, thus increasing pressure to warehouse arrested meth users in jail.
Reena Szczepanski, director of Drug Policy Alliance - New Mexico, said that local jails have become a repository for addicts because "there is no treatment program in some of the small towns in New Mexico, or if there is, it's two hours away."
According to NACo, nearly 90 percent of surveyed counties reported a rise in meth-related arrests over the past five years. Many states, including Oklahoma and Minnesota, have tried to choke off homemade, often chemically hazardous meth labs by restricting sales of the cold medication pseudoephedrine, a common meth ingredient.
Federal anti-meth policy is just starting to crystallize. Congress is considering legislation to limit meth ingredient sales nationwide. In August, the White House earmarked about $16 million over three years for meth treatment programs -- less than one percent of total drug treatment funding in 2005.
Yet, amid the growing political attention toward meth, the latest federal data shows that overall reported usage remains stable, the price of meth has declined by about 40 percent since the 1990s, and the average hit is purer than it was in 1998.
Reform groups are calling for more dialogue and cooperation between law enforcement and treatment advocates. In Szczepanski's view, targeted legislation, such as reasonable limits on meth ingredient sales to reduce home-production, could constitute "a perfectly reasonable way of implementing harm reduction at a community level." But, she added, if "we think that's going to solve the problem around methamphetamine use, we're fooling ourselves."
Rather than pursuing quick fixes, Szczepanski said, policymakers should strive for "a balance between public safety and public health."
According to some reform organizations, what they see as an imbalanced dialogue about meth reflects an underlying bias against the impacted communities. They suspect that the social marginalization of the main user groups -- rural America and gay men - - is keeping the meth debate dangerously narrow.
That political impasse emerged in sharp relief when Representative Mark Souder (R-Indiana), chair of the Subcommittee on Criminal Justice, Drug Policy and Human Resources, learned that the Department of Health and Human Services was helping to sponsor an August conference on public health approaches to meth, coordinated by the Harm Reduction Project. In a letter of protest, Souder lashed out at conferees for "trivializing or rationalizing the dangers of meth and high-risk sexual behavior."
Allan Clear, the Harm Reduction Coalition's executive director, said, "If we live in a society where we can't have those discussions, then we're not really going to come up with solutions."
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