3040 Cornwallis Road ■ P.O. Box 12194 ■ Research Triangle Park, North Carolina, USA 27709

1. From Texas to North Carolina: A Forty Year Perspective on Methamphetamine Use William Zule, Dr.P.H. First National Conference on Methamphetamine HIV and Hepatitis 2005: Science and Response Parts of this study were funded by Grants DA017373, DA13763, DA05741, DA07471from the National Institute on Drug Abuse 3040 Cornwallis Road ■ P.O. Box 12194 ■ Research Triangle Park, North Carolina, USA 27709

2. The interpretations presented here reflect the views of the author. They do not reflect the position of any funding agency or of RTI.

3. Presentation Goals • Describe the evolution of methamphetamine use in Central Texas from the 1960s through the present. • Describe methamphetamine use in North Carolina. • Compare endemic methamphetamine use with use in an emerging epidemic

4. Methamphetamine Use in Central Texas:Evolution of an Epidemic1960s-1990s

5. Primary Data Sources • Informal longitudinal cohort (1968-present) • Formal ethnographic study using semi-structured interviews and participant observation (1990-1991)

6. Central Texas TRAVIS AUSTIN BEXAR SAN ANTONIO

7. Timeline • 1950s: Oral use was common; intravenous use was present but rare • Early to mid 1960s: methamphetamine moved into the counter-culture in Austin • Late 1960s: rapid increase in the number of users • Early 1970s: used peaked and began decreasing • Mid 1970s-late 1990s: use stabilized and remained endemic through the 1990s. • 2000: Increase since 2000

8. Actions and Reactions • 1965: FDA restricted sales of pharmaceutical methamphetamine • 1968-1971:Desoxyn: script doctors and drugstore burglaries • 1970-1973: Crack down on script doctors and increase in drugstore security • 1972-1975:Rise of local labs • 1980s: Restrictions on P2P and other precursors • 1990s:Ephedrine/pseudoephedrine methods

9. 1960s Media Hype Speed Kills! “The average life expectancy of a speed freak is five years.” (Yeah, sure.)

10. Where are they now? • Most moved on to other things within 5 to 10 years. • The more successful rarely disclose their past • Some of these still use occasionally • Some are still “in the life”--using, selling, and manufacturing • Some switched to heroin after 20 or 30 years • Heavy alcohol use is common • Some are in prison • Some are beginning to die from HCV and alcohol use

11. Methamphetamine Use in North Carolina: An Early Epidemic 1990s-Present

12. Methamphetamine In North Carolina • Methamphetamine was popular in late 1960s early 1970s but was less common in the 1980s and early 1990s. • Current wave of methamphetamine use is still relatively new—since 1999. • Manufacturing and use started in the mountains of western North Carolina and spread east through rural areas across the state • Use is on the rise among MSM in urban areas (Raleigh, Charlotte) • Number of meth lab seizures increased from 9 in 1999 to 322 in 2000 NOTE: Some counties report roadside finds of trash and hazardous waste as lab seizures

13. Clandestine Meth Lab Reports 2001 2004

14. Pictures from Local Papers A hand-written note warns against entry into a mobile home in Johnston county housing a meth lab. (4-1-05) Law enforcement dismantles a meth lab in Sampson County. (3-25-05)

15. COMPARISONS

16. 1960s-1990s (Central TX) P2P method Racemic mixture of D & L isomer methamphetamine Few loosely organized manufacturers produced 5 to 100 pounds per year each in batches of 1 to 10 pounds. 1990s-Present (Central TX/NC) Ephedrine/pseudo-ephedrine reduction method High % of d-isomer methamphetamine Many small producers manufacturing batches of several grams to several ounces at a time. Imported by international drug trafficking groups Manufacturing & Distribution

17. 1960s-1990s (Central Texas) 85% white; 60% male Young adults in the 1960s-1970s Mix of heterosexual blue collar workers, motorcycle riders, musicians, criminals, and rednecks Some MSM Use in rural areas was limited to outsiders Experienced users mentored new users since mid-1970s 1990s-Present North Carolina 85% white; 60% male Young adults Mix of heterosexual blue collar workers and motorcycle riders in rural areas MSM in the cities Most rural users appear to be locals Mostly new users, limited opportunities for mentoring Characteristics of Users

18. Central Texas Majority injected Heavy alcohol use common Poly-drug use common Marijuana Cocaine Benzodiazepines North Carolina Majority smoked Alcohol use common Poly-drug use common Marijuana Some cocaine Benzodiazepines (?) Characteristics cont’d

19. Central Texas/Endemic Use Occasional -- 1-2 doses over a few hours; 24-48 hours without sleep Binge use – 3-14 day runs with minimal eating/sleeping followed by prolonged sleep (uncommon in endemic phase) Weekend use – Friday-Saturday use followed by heavy alcohol benzodiazepine use on Sunday Light daily use--A dose in the morning before work and sleeping each night Maintenance use – high dose (400-1200 mg daily) use over periods of years (eating and sleeping regularly) North Carolina/Emerging Epidemic Occasional -- 1-2 doses over a few hours; 24-48 hours without sleep Binge use – 3-7 day runs with minimal eating/sleeping followed by prolonged sleep Weekend use – limited Light daily use– not reported Maintenance use – not reported NOTE: Findings from North Carolina are preliminary. Patterns of Use

20. Patterns of Use Users in both regions reported using methamphetamine to: • engage in task oriented activities (e.g. housecleaning, fixing cars, working two jobs) • enhance recreational pursuits such as hunting and fishing in rural areas • enhance sex • Note: These activities may become repetitive and destructive

21. Summary: Everything Old is New Again • The current epidemic parallels the earlier epidemic in: • Race and gender of users • Initial heavy/binge use patterns • “Crisis” response from media and policymakers

22. Key Differences • More potent d-isomer form of drug • Smoking as predominant mode of administration • Increased use among urban MSM and rural heterosexuals • Role of imported methamphetamine

23. The “Crystal” Ball (aka The Good News?) • What does history tell us about what might happen in NC (and other rural areas)? • Use will peak then begin to decline, becoming endemic to subpopulations • Patterns of use will change • Uncontrolled binge use will fade • “Controlled” use will become more common • Smoking will probably result in decreases in HCV transmission • New laws and enforcement will limit local manufacturing

24. Unanswered Questions • Will smoking lead to wider diffusion? • Will reductions in injection-related HIV risk be offset by increased sexual risk across wider segment of population? • What percentage of smokers will transition to injection? • What impact will imported methamphetamine have on: • Future domestic production? • Diffusion of methamphetamine to minority populations?

25. Acknowledgments I would like to thank all of the people who have shared their thoughts with me, formally or informally, over the years.