**Recommendations to the State of South Dakota to Address the Problem
Created by Methamphetamine Abuse and Dependence**

**Technical Assistance Report from Richard Rawson, Ph.D.**

**UCLA Integrated Substance Abuse Programs**

**Based on a site visit to Sioux Falls, South Dakota**

**June 8 and 9, 2005**

**Introduction**

The State of South Dakota has recognized a substantial increase in
methamphetamine (MA) use over the past decade. They requested and
received a 2 day technical assistance visit (June 8 and 9)in Sioux
Falls, South Dakota to review and discuss the nature of their problem
with MA and develop a comprehensive public health strategy to
effectively address the needs of the citizens of South Dakota. During
the 2 day visit, conducted, by Richard Rawson, Ph.D., Adjunct Associate
Professor, UCLA Department of Psychiatry and Biobehavioral Sciences,
approximately 150 individuals from the South Dakota SSA and treatment
and other service providers participated in training and information
collection sessions. On June 8, a presentation of the nature of the MA
problem was delivered by SSA Director, Gil Sudbeck, followed by a day
long training by Dr. Rawson. On, the 9^th^, discussions were held with
the group to ascertain the clinical challenges, treatment service gaps
and other unmet needs that currently faced the South Dakota substance
abuse service delivery system. This report includes an overview of the
current MA-related challenges faced by the health, mental health, social
service and substance abuse systems in the State of South Dakota. In
addition, a set of recommendations are made to better equip the systems
in the state to more adequately meet these challenges.

> **Background and Needs**

The 2004 census documented the population of the State of South Dakota
to be 770,883. Ethnicity of the State is 94% White; 0.7% Black; 2.1%
American Indian/Alaskan Native; 1.4% Hispanic/Latino; 1.8% 2 or more
races. Reports from criminal justice authorities have documented the
increase in MA production in South Dakota as evidenced by a rapid
increase in the number of laboratories seized and the amount of MA
confiscated by police. Although the number of laboratory seizures
appears to have stabilized by 2005, it has been reported that Mexican
methamphetamine is increasingly available in South Dakota. Another
important indicator of the extent and growth of the MA problem is
demonstrated by the increase in MA-related treatment admissions into the
State's treatment system. During the 2002-2003 fiscal year MA related
admissions (n=1405) represented 11% of all admission into the South
Dakota treatment system. Two years later the number of MA users admitted
into the system (n=1862) represented 15% of all admissions, a 2 year
increase of 31%. Of particular concern, is the high rate of injection
use, as research has shown that up to 70% of individuals who use MA via
injection are positive for Hepatitis C. Across the 2002-2005 period
approximately 34% of all individuals who were admitted into treatment
for MA use in South Dakota reported use of MA by the injection route of
administration. These numbers included 85 pregnant women who used MA (35
by injection route) and 329 adolescent MA users (59 by injection route).

Leaders in South Dakota have recognized that the existing drug
prevention and treatment services are not fully meeting the needs of the
citizens of South Dakota. The areas of needs were clearly articulated in
the June 9 discussions. Included among the system needs expressed were:

**Methamphetamine Prevention Knowledge is needed for**:

-General Public

-College Students

-Women

-Adolescents

-Judges and other Criminal Justice Personel

-Native Americans

-Medical Providers (MDs and Nurses)

-Educators

-Social Service System professionals

**Methamphetamine Treatment Knowledge is needed for:**

[Medical Providers:]{.underline}

To recognize signs and symptoms of MA use, including MA-induced
paranoia,

psychosis, anxiety, depression, weight loss, skin and dental problems

> To routinely use substance abuse screening techniques, including
> screening questionnaires and biological testing in primary care
> settings

To deliver brief interventions to individuals at initial stages of use

> To effectively refer individuals who abuse or who are dependent upon
> MA into the substance abuse treatment system

To properly screen for infectious diseases (i.e. Hepatitis C; and HIV
especially

among gay men)

To screen pregnant women for MA use

To recognize signs and symptoms related to exposure to the manufacture
of MA

in home labs (eg. poisoning with precursor chemicals)

To recognize signs of domestic violence associated with MA-related
violence

To recognize the needs of drug endangered children

[Mental Health Providers]{.underline}

> To recognize symptoms of MA use and distinguish these symptoms from
> other psychiatric illnesses
>
> To develop treatment plans that address individuals psychiatric and
> substance abuse treatment needs in an integrated manner
>
> To become familiarized with the substance abuse service delivery
> system in South Dakota and how to effectively access substance abuse
> services for individuals in the social services systems
>
> To establish proper linkages with the substance abuse service delivery
> system to ensure complimentary services that promote integrated care

[Social Service Providers]{.underline}

> To routinely screen individuals for MA use and other substance use
> problems
>
> To recognize the signs and symptoms of MA use, as demonstrated by MA
> users and the children of users and MA "cookers"
>
> To become familiarized with the substance abuse service delivery
> system in South Dakota and how to effectively access substance abuse
> services for individuals in the social services systems

[Substance Abuse Treatment System Professionals]{.underline}

To understand the effects of MA on the body, brain, family, community

> To understand the key processes in recovery that are critical for the
> proper treatment of MA dependent individuals, including,
>
> -conditioning and learning processes,
>
> \- craving,
>
> \- withdrawal symptoms,
>
> \- MA-related paranoia,
>
> \- MA and sexual behavior,
>
> \- MA route of administration,
>
> \- timetable of recovery, especially the extended anhedonia,
>
> \- relapse prevention strategies,
>
> \- issues related to MA-associated violence,
>
> \- trauma to women and children,
>
> \- issues surrounding relapse due to weight gain,
>
> \- issues about alcohol and marijuana use and relapse to MA,
>
> \- need for long term social support in a peer support system
>
> To learn to identify individuals who are in need of medical and/or
> mental health treatment and how to link individuals with these
> services
>
> To learn effective referral/linkage and case management strategies to
> reduce drop out and treatment compliance failures within different
> levels of care in the substance abuse service system and between the
> substance abuse services systems and other parts of the health and
> social service system
>
> To develop specialized skills to recognize and treat MA use disorders
> in special populations (eg, adolescents, pregnant women, gay men, MA
> users in the criminal justice system, Native Americans)
>
> To learn specific skills for treating individuals with MA-related
> disorders using effective training materials developed by NIDA and
> SAMHSA (eg. CSAT TIPs) including the following:
>
> Motivational interviewing
>
> Cognitive behavioral therapy
>
> Contingency management techniques
>
> Matrix model
>
> Family systems techniques
>
> 12 Step facilitation materials
>
> Case management skills
>
> Trauma related therapies (especially for women)
>
> Drink/and drug use refusal skills
>
> Telephone out reach/aftercare strategies
>
> To introduce accurate MA educational information into treatment
> settings
>
> To apply strategies to enhance treatment engagement and retention as
> developed by the CSAT/RWJ NIATx program
>
> To raise the visibility of the fellowship of AA and NA with
> individuals in MA treatment and for those in the community who have
> not entered treatment
>
> To explore situations, circumstances and settings in which mentor
> strategies can be effectively used
>
> To explore the use of drug court mechanisms for MA dependent
> individuals who become involved with the criminal justice system
>
> To improve the knowledge and treatment effectiveness of substance
> abuse treatment services in prisons
>
> To develop cultural sensitivity to enhance treatment system
> effectiveness with Native American participants and create linkages to
> reservation and IHS systems of care
>
> To improve the knowledge and skills of staff working with adolescent
> substances users who may be initiating use of MA, but may not be
> dependent
>
> **Treatment for Methamphetamine Dependent Individuals**

There have been a number of recent efforts to examine the questions
about whether or not individuals who use MA can be successfully treated.
Results of these investigations have clearly confirmed the MA users are
treatable and their outcomes are similar to other substance dependent
individuals. However, it is also clear that treatment efforts with MA
users can be improved if empirically supported treatment strategies are
used.

Presently, there are two approaches that have evidence to support their
efficacy for the treatment of MA dependence, but there is a much larger
literature on treatments that work with the other major illicit
stimulant problem in the U.S., cocaine dependence. Although there are a
number of differences in the pharmacology and physiological effects
produced by MA and cocaine, these drugs have many common properties and
similar effects. Research examining the treatment responses of MA and
cocaine users suggests that cocaine and MA users have very similar
outcomes when exposed to the same treatments. In addition, large scale
treatment system evaluations have reported comparable outcomes for
cocaine and MA users.

To date, the majority of studies investigating the effectiveness of
treatment for stimulant addiction have focused on cocaine abuse with
fewer studies on MA. Despite differences between the two stimulants in
individual health, psychological and cognitive effects, both groups tend
to show comparable responses to psychosocial behavioral treatments. In
one large study using the Matrix Model, 500 MA dependent individuals
were treated alongside 250 cocaine dependent individuals at the same
clinic, by the same staff, over the same time period, using the same
approach. Treatment outcomes were identical both during treatment and at
follow up. Similar findings have been reported from treatment studies in
San Francisco and from data collected in Los Angeles County and
throughout California. While there is absolutely no evidence that MA
users and other drug user populations respond differently to treatment,
there are multiple controlled and large scale treatment outcome studies
that suggest that treatment outcomes for MA and cocaine users

is very comparable. Taken together, these results tend to dispel the
false beliefs about treatment effectiveness for MA addiction circulating
within the public sphere.

[Matrix Model]{.underline}: During the 1980s, the Matrix Institute on
Addictions group in Southern California (including the present author,
Rawson), created a multi-element treatment manual with funding support
from NIDA, designed for application with stimulant users on an
outpatient basis. The Matrix approach evolved over time, incorporating
treatment elements with support from scientific evidence, including
cognitive behavioral therapies (i.e., relapse prevention techniques), a
positively reinforcing treatment context, many components of
motivational interviewing, family involvement, accurate
psychoeducational information,12-step facilitation efforts, and regular
urine testing. The approach is delivered using a combination of group
and individual sessions delivered approximately three times per week
over a 16 week period followed by a 36 week continuing care support
group and 12 step program participation. Over 15,000 cocaine and MA
users have been treated with this approach during the past 20 years. The
manual and related materials have been published by Hazelden and SAMHSA.
(for more details see [www.Hazelden.org](http://www.Hazelden.org/) and
[www.SAMHSA.gov](http://www.SAMHSA.gov/).)

A particularly interesting finding was that across the 8 treatment
sites, the 'drug court site', e.g., the one that enrolled individuals
who were participating under a drug court program, produced superior
results compared to the other 7 sites, suggesting a substantial
beneficial influence of drug court involvement. Overall, this evaluation
is the largest controlled study of MA treatments that has yet to be
conducted.

[Contingency Management (CM)]{.underline}: Positive reinforcement is a
powerful tool in increasing desired behaviors. School teachers who have
given 'special prizes' for superior performance, companies who give
employee incentive bonuses for meeting production goals, AA meetings
that give 'chips' and cakes to acknowledge successful progress in
achieving sobriety are all examples of the effective use of positive
reinforcement. Many existing treatment programs informally use positive
reinforcement as part of their treatment milieu. Frequently, the
reinforcement takes the form of verbal praise, or earning program
privileges, or 'graduating' to a higher level of status in the program
or some other practice to acknowledge and reward progress in treatment.
CM is simply the systematic application of these same reinforcement
principles. In many of the studies investigating CM approaches,
treatment participants can earn 'vouchers' that are exchangeable for
non-monetary desired items (e.g., free movie tickets, restaurant
dinners, grocery vouchers, gasoline coupons, etc.). Typically the
individual can earn larger valued rewards for longer periods of
continuous abstinence from drugs and alcohol.

Recently CM techniques have been implemented with MA users in Southern
California by the group at UCLA and by researchers in the NIDA Clinical
Trials Network. The results of these investigations have provided
powerful support to the efficacy of this behavioral strategy as
treatment for MA abuse. Individuals who have been assigned to CM
conditions have shown better retention in treatment, lower rates of MA
use and longer periods of sustained abstinence over the course of their
treatment experience. Without question, CM is a powerful technique that
can play an extremely valuable role in improving the treatment response
of MA-dependent individuals.

[Implications for MA Addiction Treatment:]{.underline} *Psychosis, Route
of Administration, Sex, Infectious Diseases, Women and Kids*

Much of the ambivalence about MA treatment effectiveness stems from
sentiments that 'meth abusers are difficult to treat,' quoted by many in
the field and press. Studies have identified unique characteristics of
MA abusers that may pose many clinical challenges that are frequently
more problematic than is seen with standard treatment populations. MA
abusers come to treatment with unique demographic and health profiles.
For instance, MA abusers have been consistently observed to experience
severe psychiatric problems, including psychoses, hallucinations,
suicidal ideation, and severe depression and cognitive impairments when
presenting for treatment. At present, it is not clear how much of the
psychiatric symptomatology is directly related to the effects of the
drug and what role co-morbid disorders are involved. Clearly, however,
clinicians treating MA have to be educated about working with patients
who have clinically significant levels of disordered thinking and
persisting paranoia.

Historically, MA use has been via intranasal and injection routes of
administration. However, in the past decade, smoking has become the
dominant route of MA administration, and more recently some geographic
areas (e.g., South Dakota) have reported elevated rates of MA injection.
Smoking and particularly injecting MA appears to lead to a more
difficult addiction to address. Injection users tend to report far more
severe craving during their recovery and they have higher rates of
depression and other psychological symptoms before during and after
treatment. They also have higher drop out rates and exhibit higher rates
of MA during treatment. In addition, recent reports have documented the
extremely powerful relationship between MA use and sexual behavior.
Individuals who use MA describe a far more powerful association between
MA and sexual behavior than cocaine, heroin or alcohol users. Issues
around sexual readjustment during sobriety are very important and can
play a very big role in relapse, if not properly addressed.

In a recent sample of MA users who entered treatment in the Midwest,
Hawaii and California, the rate of Hepatitis C infection was 22%. Of the
MA injectors, over 70% tested positive for hepatitis C (Hep C). Clearly,
there needs to be a strong message about behaviors that expose
individuals to Hep C infection (blood to blood transfers) in treatment
and prevention efforts. In addition, MA use is associated with very high
risk sex and has been shown to be a huge factor in HIV transmission
among gay men. Research by Shoptaw, Reback and colleagues in Los Angeles
has shown that MA use is the biggest threat in the gay community to
producing a renewed spread of HIV. They have developed treatment
materials for this group and have shown that successful treatment of MA
dependence is an extremely effective HIV prevention strategy.

Women use MA at rates equal to men. Use of other major illicit drugs is
characterized by ratios of 3:1 men to women (heroin) or 2:1 (cocaine),
in many large data sets, the ration for MA users approaches 1:1. Surveys
among women suggest that they are more likely than men to be attracted
to MA for weight loss and to control symptoms of depression. Among
women, MA abuse may present different challenges to their health, may
progress differently, and may require different treatment approaches.
Over 70% of MA dependent women report histories of physical and sexual
abuse, as well as more likely than men to present for treatment with
greater psychological distress than males. Many women with young
children do not seek treatment or drop out early due to the pervasive
fear of not being able to take care of or keep their children as well as
fear of punishment from authorities in the larger community.
Consequently, women may require treatment that both identifies her
specific needs and responds to them.

These unique clinical symptoms commonly experienced among MA abusers
suggest that effective treatment of MA abusers should be comprehensive,
including greater emphasis on infectious disease transmission and other
psychosocial issues. While these differences highlight the importance of
developing more effective treatment models for MA addiction, studies
have shown that treatment response using similar treatments is highly
comparable between MA users and cocaine users. Thus, it can be argued
that it is not necessary to design completely new approaches for MA
addiction. Rather, focus should be targeted at enhancing existing
treatment regimens with supplemental type services that address these
underlying differences among the MA patient.

**Recommendations for South Dakota to Address Methamphetamine**

[Prevention Recommendations]{.underline}

Develop or obtain from other sources, public service announcements for
television, radio, and internet to educate the public about the dangers
of MA use. Tailor for maximum impact on adolescents, women and Native
Americans. Educate about the extreme dangers of injection MA use
(Hepatitis C).

Develop and implement a plan to educate judges and court officers, high
school teachers, social service personnel about effects of MA and the
benefits of MA treatment

Maximize the use of "early use" protocols designed to deter drug use by
adolescents and young adults who may be experimenting with MA. Integrate
accurate MA information into these programs

[Health System Recommendations]{.underline}

Develop and implement a plan to educate medical personnel to identify
individuals who are using or otherwise affected by MA (domestic violence
and child abuse neglect). Include in the training, how to deliver brief
interventions and conduct make effective referrals to substance abuse
services system. Train in the use of motivational interviewing
approaches to increase the ability of medical personnel to deliver
referral recommendations in a manner that will facilitate patient
compliance.

Develop and implement a plan to educate medical personnel to identify
individuals who are using or otherwise affected by MA (domestic violence
and child abuse neglect). Emphasize the nature of MA-induced paranoia
and psychosis and protracted withdrawal symptoms of depression,
anhedonia, anxiety and the distinctions between MA-related symptoms and
similar symptoms resulting from other psychiatric disorders.

**Substance abuse service delivery system**: Within the substance abuse
service delivery system, increase the theme of system linkages and the
creation of a multi-element system/continuum of care. Create a treatment
attitude among providers that endorses and emphasizes the value of
maintained care within a multi-element system. This attitude views
recovery as a long term process during which individuals frequently
improve and develop successful non-drug using lives, often with the
support to peer fellowships (AA and NA). However, this view also
recognizes that treatment is a long term process of teaching and
supporting lifestyle change, during which individuals require different
forms of treatment at different times in their recovery. Use of a full
continuum and strategies to move individuals to appropriate service
levels should be emphasized. Outpatient treatment is clearly the
modality that provides the most cost effective and clinically
appropriate setting for much of the treatment for MA-using individuals.
Outpatient treatment protocols should be developed using the strategies
that have been developed in NIDA and SAMHSA literature that will
successfully engage and retain individuals in treatment. These protocols
can be constructed to have decreased frequency of contact over time as
individuals become more stable/successful in their recovery, and
conversely, intensify when needed to provide additional support when
individuals experience relapse of recognize increased vulnerability to
relapse. Additionally, telephone contact, as a therapeutic aid, mentor
support and possibly internet support may be all useful tools in
creating a support system that goes into the community to provide
support for users. Of course, the 12 step recovery program is an
essential element in helping MA users to build a network of support in
the communities where they live. Treatment programs would do well to
work within their communities to build strong and positive bridges
between formal treatment and the support in the self help fellowships in
the community.

A particularly challenging task in treatment is the successful
engagement of MA dependent individuals into treatment. For those
individuals, whose addiction is so severe as to be characterized by
psychosis, paranoia, severe withdrawal related depression, medical and
other psychiatric symptoms an initial period of medically supervised
"detoxification and stabilization" in a medical or medically supervised
residential setting may be necessary and for many individuals,
essential. This level of care is expensive and should only be viewed as
needed to either provide a supervised, safe and medically monitored
setting to help severely impaired individuals initiate treatment or be
used in those cases where an individual has returned to MA use (become
readdicted) and needs to restabilized. The goal of the stay during the
period of residential care should be to ensure the medical well being of
the individual and to help them gain a period of MA abstinence. A major
focus should be on ensuring that the individual will move directly from
this intensive, residential level of care into involvement in outpatient
treatment. The linkage between the residential setting and the
outpatient service is one of the most critical issues in a successful
system of care for MA users. Failure to build complimentary treatment
services, employing similar treatment approaches, languages,
philosophies is one of the major sources of service system
inefficiencies. Individuals treated in residential care who do not
successfully move into outpatient care experience very high levels of
relapse and re-addiction. Creating systems of care that are compatible
and that use empirically supported tools to improve retention (eg.
motivational interviewing and contingency management), are an essential
steps.

There are certainly circumstances in which more intensive levels of care
(residential setting) are needed. These include treatment for some
individuals with concurrent psychiatric disorders, homeless individuals,
women with children, some individuals coming directly from prison
treatment programs and some individual who simply are not able to
maintain abstinence on an outpatient basis, despite best efforts. The
degree to which residential level services are available for these
individuals is dependent to some degree on the available level of
service resources available to the state.

Specific Action:

Much of the suggested training on treatment techniques and manualized
approaches and for various target groups, can be brought to South Dakota
by expert trainers, with assistance of the ATTC in the region. However,
the creation of a system of care that can move patients through with
linkages between settings and programs can only be done by the providers
themselves, with leadership from the SSA. Certainly, it would be useful
to have an outside consultant work with the SSA and providers to build a
linked system, but only if this linked system is created by the actual
providers, will it be successful. It will require an active process that
will take an extended period to successfully create. However, if the
providers can be engaged in such a process, with an accepted vision, a
tremendously enhanced treatment system could be developed in South
Dakota that could optimally meet the needs of MA users.