At the San Francisco AIDS Foundation, staff members Tyrone Clifford (left) and Rick Andrews demonstrate how a contingency management visit typically begins, with a participant picking up a specimen cup for a urine sample. If the sample tests negative for meth or cocaine use, the participant has an incentive dollar amount added to their 'bank,' which can later be traded for a gift card. (Courtesy San Francisco AIDS Foundation)
The first time Rick Andrews did speed, he was with his boyfriend at a gay pride party. He still remembers how happy it made him feel, how utterly euphoric, and strong. Like Superman.
Andrews grew up in Palo Alto in the 1960s and '70s and he says, back then, there was so much shame around being gay. His self-esteem was chronically low. Meth made all that disappear.
“All anxiety fell away, insecurities, anything that was negative, just dropped away,” he says. “And the sex was great. It’s hard to describe just how powerful it is.”
Andrews, now 59, says it took years of therapy to find that self-confidence and hot sex without speed. Now he counsels other methamphetamine users, and he sees the same struggle repeating throughout San Francisco’s gay community.
“Meth becomes the answer to the shame and the great sex, and it’s not,” he says. “That’s when you’re giving it too much power, and that’s when things fall off the rails.”
As San Francisco faces a resurgence of meth, with spikes in meth-related deaths, emergency room visits and hospitalizations, health officials are grappling with the limited treatment options available for meth addiction.
For opioid use disorder there are three FDA-approved medications people can take to reduce cravings and withdrawal symptoms, and all are pretty effective. For meth and cocaine, there’s nothing.
“We have a giant, gaping hole where we don’t really have much of anything for stimulant use disorders,” says Dr. Phillip Coffin, director of substance use research at the San Francisco Department of Public Health.
Researchers have been through dozens and dozens of clinical trials, looking for a medication to treat meth, Coffin says, and they all failed. He’s conducted several of the trials himself.
He’s tried four possible medications: Wellbutrin, an anti-depressant that’s also used for smoking cessation; aripiprazole, an anti-psychotic; extended-release naltrexone, which helps with opioid and alcohol dependence; and mirtazapine, another anti-depressant.
The only one that showed any promise at reducing meth use was mirtazapine.
Coffin studied the drug in a small group of men who have sex with men in San Francisco, and over 12 weeks, the men who took the anti-depressant showed a 40 percent decrease in meth use, compared to a 6 percent drop among men who took a placebo. Coffin is now testing the drug on a larger group to see if the initial results hold up.
“People who have a methamphetamine use disorder can sometimes find it hard to take medications on a daily basis, and that’s a big challenge for clinical trials,” he says.
The other challenge is human brain chemistry, says Dan Ciccarone, a professor and substance use researcher at the UCSF.
Human brains have opioid receptors, so it’s easier to tailor a medication that targets them specifically, he says.
“Methamphetamine doesn’t work through a single receptor,” he adds. “It stimulates multiple parts of the brain in multiple parts of the body. There’s too many targets.”
What does seem to work for meth users is counseling, cognitive behavioral therapy and something called contingency management. Basically, every time users pee in a cup and test negative for meth, they get paid.
“You can imagine that it rubs people the wrong way to pay active drug users to not do a drug,” Ciccarone says. “The truth is, incentives work for all of us. If you want to lose weight, change a habit or get your kids to change a habit, incentives work.”
This is at the heart of what Rick Andrews does now, running a 12-week program at the San Francisco AIDS Foundation to help guys get their meth use under control. It’s called the Positive Reinforcement Opportunity Project (PROP), and guys come in three days a week for drug testing and counseling.
The payments start small: $2 for every negative test, then gradually increase to $10 for every negative test. If someone tests positive, they get nothing for that visit, but they are encouraged to stay for counseling and to come back the next testing day to try again, Andrews says. At the end of the 12 weeks, if all tests are negative, the client gets $330.
“It’s something that can give them a little power,” Andrews says.
Clients will tell Andrews, “Oh, there’s something on Amazon I’ve been wanting to get.” Or, “I want a tattoo.” Others use the money to pay their phone bill or gym membership.
“It’s a reward system,” Andrews says, the carrot as opposed to the stick. “It gives them something to work toward.”
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