Providing a New Start Through Meth Treatment

Cedar Crest Hospital and Residential Treatment Center is located in Belton, Texas, in a largely rural community near the state's center. It serves children ages 4 to 17 from the entire state, and operates its own charter school. It has become clear in recent years that the elements necessary to produce the drug methamphetamine (ammonium sulfate, iodine, red phosphorus, ephedrine) are in ready supply in the local community.

Sold locally under the street names of “crystal,” “ice,” or “blue ice,” methamphetamine produces a much longer-lasting high than cocaine and is sold much more cheaply than cocaine in similar quantities. Whether smoked, injected, or snorted, meth is readily absorbed and affects both dopamine and norepinephrine neurotransmitter systems. Patients arriving here for treatment often appear delusional and have significant memory and concentration problems associated with use. About once a month, a young patient is abandoned by his/her parents to the hospital.

One factor that exacerbates the drug's effects is that sanitary conditions are often not kept in the cooking of the chemical. Anhydrous ammonia, a toxic chemical, is expelled into the air in the preparation process, which can impair the cooker.

We find that our young patients frequently start abusing drugs because of the influence of a family member—often a parent. Treatment on occasion may expand to involve an intervention on an impaired parent who has sent his/her child to treatment rather than deal with his/her own issues. About half of our young patients are in the custody of child protective services. For children in our care who have reasonably intact families, listening to the stories of patients in state custody becomes an eye-opening experience. Tales of parental abandonment and abuse usually generate a gratitude response from children whose families may be dysfunctional but remain together.

Presenting problems

Methamphetamine patients are dysphoric and often physically ill, and can need significant dental work as meth affects the immune system and leaves users susceptible to infection. Patients often pre-sent with tremors, cognitive deficits, evidence of memory loss, recent weight loss, sleep deprivation, and paranoia. Oppositional defiant disorder or conduct disorder is routinely diagnosed along with the substance abuse. Lack of major accomplishments of late manifests in academic, social, and family problems, resulting in low self-esteem. Faced with this level of damage, Cedar Crest must focus first on medical stabilization.

Our average patient is 14 or 15 years old and meets criteria for polysubstance dependence. Methamphetamine is ac-companied with use of marijuana, alcohol, or Xanax to mitigate the drug's unpleasant side effects. Even at this young age, many patients have had three or more years of pathology; they likely stole, traded sex for drugs, or sold drugs to support the habit. Patients present with projection and denial, having little if any insight into the severity of their problems.

Our patients often present with significant weight loss, malnutrition, labile mood states, and aggression. Many have lesions about the body and face as the body deals with the methamphetamine. This damage to patients' appearance tends to exacerbate depressive symptoms. These patients are often angry and cynical, and often have suicidal ideation.

Stressing treatment continuity

Treatment within this program consists of a multidisciplinary series of assessments, including assessments for sexual abuse and physical assessments for malnutrition. All patients receive a full physical upon admission. We arrange for dietary intervention along with chemical dependency and psychiatric counseling.

We have experienced a high co-occurrence of sexual trauma in the group (in excess of 50%), and we offer trauma recovery groups. Females' recounting of trauma can go a long way toward sensitizing young men who have engaged in dealing.

With average lengths of stay of only 14 to 21 days, we have built close relationships with outpatient service providers throughout the state; they work with us to step down the level of care for our patients at the conclusion of inpatient treatment. Given the diversity of problems affecting this category of patient, it is safe to say that all would benefit from increased lengths of stay in treatment.

Out of necessity we take a harm reduction view of treatment and focus on stabilization and reduction of anger, and we use Motivational Interviewing techniques to facilitate change. We aim for a more positive attitude toward continued treatment as our main outcome goal. Unlike the typical 28-day model, our services focus on physical and psychological stabilization and what we used to call “pretreatment.” The “real” treatment episode by necessity must be done on the outpatient level post-stabilization.

Cedar Crest employs Terence T. Gorski's developmental model of recovery (outlined in SAMHSA Technical Assistance Publication 19 on relapse prevention for chemically depen-dent criminal offenders). This provides sufficient justification that the patient should stay in some level of care throughout the first year of sobriety. Stepping down to another provider leaves the door open for patients not to continue in treatment at the outpatient level and to relapse. Despite our efforts to make this transition seamless, it is not uncommon to re-admit a patient who has become more severely ill than at the previous admission.

Educational approach

Treatment addresses the psychosocial and spiritual effects of the disease. Two group sessions take place each day, and there are weekly family and individual sessions, with a focus on life skills. Didactic therapy focuses on sharing the most recent scientific findings as a strategy for combating the guilt and shame often accompanying the disease. Treatment addresses patients' often negative feelings that result in self-defeating behavior.

Patients evaluate their own progress weekly, reporting on where they are situated in the stages-of-change model. Self-reporting is encouraged with parents and, where applicable, legal authorities. Patients are encouraged to self-report to legal authorities to demonstrate compliance with current court orders. In Texas, 16-year-olds can be adjudicated as adults; this often provides an incentive to seek treatment.

Since our patients often arrive with a more complicated diagnostic picture involving both substance abuse/dependence and psychiatric problems, we collaborate with our psychiatrists for co-occurring disorders treatment and medication management. This consists of medical stabilization, treatment of physical and psychological withdrawal, and treatment of any comorbid psychiatric disorders and their symptoms.

Our psychiatrists utilize medication treatments (such as antipsychotics) prudently in order to help patients attain an initial period of abstinence and to assist in relapse prevention. Adequate medication management of co-occurring psychiatric and medical problems also helps ensure that these issues do not complicate the healing process.

Treatment consists of material that is educational and informative. Our research-based curriculum is based largely on Gorski's relapse prevention concepts, as well as the Dialectical Behavioral Therapy model of Marsha Linehan of the University of Washington. Our 12-Step modality is from Debbie Webb of the University of Texas School of Social Work, who also oversees behavioral health services at the Austin Travis County Mental Health Mental Retardation Center. This is a facilitated 12-Step program for those with co-occurring disorders. Balance is the key to this program, with a clear focus on the differences between recreational and therapeutic use of medications.

Finding interesting age-appropriate material poses a constant challenge, as patients often view age-appropriate material as condescending. Our treatment consists of addressing the uneven development that occurs during using. Our patients often have a highly sophisticated street persona, with limited problem-solving and emotional development. They express boredom toward most materials directed to adolescents.

Patients who succeed in our program are expected to continue treatment on an outpatient basis—otherwise, the challenge of returning to their family of origin and the people with whom they previously associated will be overwhelming. The social component of this disorder cannot be overlooked. In our experience, by the time a patient has two or three years of using it is uncommon for them to have any non-using friends. Therefore, continuing in treatment, support groups, and the like offers the only effective strategy to complete the resocialization necessary to maintain sobriety.