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The Honolulu Advertiser
Posted on: Sunday, February 12, 2006

COMMENTARY
Ice and the search for a political solution

By Dr. William Haning

Sudafed pills can be used in the production of crystal meth, shown in the tube at right, and the drug's powder form, left.

Gannett News Service

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DRUG LEGISLATION PENDING

Here are some of key bills that address Hawai'i's substance abuse problem, particularly the crystal methamphetamine (ice) epidemic:

CLINIC FOR WOMEN (SB2132/HB2045)

Establishes funding for a pilot clinic to provide comprehensive prenatal, delivery, and postpartum care and social services on the island of O'ahu to women with a history of ice and other substance use.

Next step: Senate Ways and Means Committee, (586-6460); House Higher Education Committee, (586-9450)

TREATMENT PROGRAM (SB2364/HB2401)

Establishes a drug abuse intervention and treatment program enabling referral of patients receiving trauma treatment, and repeals an insurance provision that now discourages such referrals.

Next step: Senate Health Committee hearing on SB2364, 2:30 p.m. Monday in conference room 016; call (586-6070); House Consumer Protection and Commerce Committee, (586-8400).

GRASS-ROOTS EVENTS (SB2409/HB2521)

Appropriates $200,000 for community-based anti-drug and substance abuse events in Hawai'i county.

Next step: Senate Health Committee (586-6070); House Finance Committee (586-6200).

COORDINATE ANTI-DRUG PROGRAMS(SB2765/HB3120)

Appropriates up to $350,000 per school complex for existing or emerging community coalitions to coordinate anti-drug programs, fill service gaps, and implement prevention programs.

Next step: Senate Health (586-6070) and Education (586-8585) committees; House Health Committee (586-6050).

FACILITY, HELP FOR CONVICTS (HB508)

Appropriates funds for a 600-700 secure-bed facility for convicted drug offenders for substance abuse treatment and other programs.

Next step: Referred to: Public Safety/Military Affairs Committee (586-8470).

'DRUG BUSTERS' PROGRAM (SB1201/SB577/HB361/HB1184)

Establishes the "Drug Busters" program in the Department of the Attorney General to enforce methamphetamine (ice) laws.

Next step: Senate Judiciary (586-7793) and Health (586-6070) committees; House Judiciary (586-8530), Health (586-6050) and Public Safety (586-8470) committees.

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While everyone has heard that ice (methamphetamine) use is an epidemic in Hawai'i, what's needed is an understanding of what that means, and what it implies about how to manage this problem.

Recent studies and statistics show that in Honolulu, 40 percent of all males arrested and 57 percent of all females arrested in 2003 tested positive for methamphetamine. Twenty percent of emergency-room visits in 2004 were directly associated with methamphetamine use. And 4.1 percent of 12th-graders had used methamphetamine in 2003.

Indeed, Hawai'i leads all other states in ice use per capita.

Hawai'i's unique status in the world of ice addiction stems from some pretty mundane reasons: We are on shipping routes that allow easy market capture by Asian manufacturers of ice; we have a service economy with both parents in a family typically working long hours and commonly holding second or even third jobs; when ice entered Hawai'i, it was in the smokable form, which was much more convenient and popular than nasal, oral or injectable forms; and there was far less competition from cocaine than was seen in other U.S. states.

Ice use in Hawai'i is genuinely epidemic:

  • It has the qualities of contagion a causative agent which can reliably cause the illness, transmission from person to person, and other qualities that make this resemble cholera, typhoid, tuberculosis or AIDS.

  • It also has a number of qualities relating to the marketplace. That's not so surprising. There is no methamphetamine food bank the user must be willing to pay money for it, or to provide something of value. The principles of distribution are strikingly similar to those used to distribute or indeed even to create a market for Pepsi-Cola or Coca-Cola. You have to establish that the product does something for people. And on some level, you have to advertise, even if it is only person-to-person. Then you have to work out the details of distribution.

    Of course, many aspects of marketing, such as taxation and regulation, are blissfully absent for the would-be ice marketer. But there are several issues that are just plain mundane, such as how to warehouse the drug, what sort of transportation or courier system you must use, how it should be packaged and dispensed, and determining who constitutes eligible shareholders in the marketing enterprise.

    Methamphetamine has been marketed and used in all of those ways for as long as 70 years. In the late 1980s and early 1990s, crystal methamphetamine that could be heated up, smoked and inhaled first became popular in Hawai'i. One of the earliest reports in the literature of this comes from Dr. Tom Nestor, a Kaiser internist, who first described the effects on the lungs of a single person with methamphetamine use in the Journal of the Hawai'i Medical Association in 1989.

    Now, the dominant form of methamphetamine use is to inhale it, and almost all of it comes from Asia. The reasoning for the origins are fairly simple: The purity of methamphetamine from Asia is almost always of a pharmaceutical grade, which contrasts markedly with methamphetamine made in home laboratories in the Midwest, which is frequently impure and tainted with lead or other contaminants. This is not puzzling. Methamphetamine is not difficult to manufacture, and it actually is easier to make large quantities of clean methamphetamine in a controlled, clean environment and consequently make the profit on bulk than furtively in cramped kitchens using makeshift instruments and chemicals. It helps not to have the police knocking at your laboratory door, another competitive advantage for the overseas labs.

    The routes of methamphetamine administration are as with many other drugs: orally; by injection, either intravenously or even into the muscle; by insufflation, that is, by snorting it in the nose; or by heating it and then inhaling it. It also is possible to take in methamphetamine rectally, but this option is seldom used.

    How you take in methamphetamine seriously affects the way you react to it. Taken as a tablet, in small doses, it very slowly reaches therapeutic blood levels for treatment of certain problems such as attention deficit disorder in kids, and it stays at a therapeutic level for a long time. If you go to the extreme of inhaling it, methamphetamine levels in the blood will shoot sky high within seconds and then begin to fall off very rapidly. There the methamphetamine level will then remain, causing some effect for a period of hours. If the user repeatedly inhales it, it creates a sustained blood level lasting for many hours or even a day.

    Methamphetamine users, at least at first, use the drug for what they feel are solid reasons. But most of the time, their initial use of methamphetamine is simply the curse of humanity: curiosity and the need to respond to peer pressure. And methamphetamine like every other drug has effects that are seen as beneficial to the user, at least at first.

    Because it suppresses appetite, keeps the user awake, gives a sense of energy and may improve attention, it has particular appeal to people who work long, arduous hours. Traditionally, the drug has had its widest appeal to those in difficult and usually low-paying jobs, such as garment manufacture, agriculture, basic construction, food services; those are the folks who work two or more jobs to pay the rent. If you are using it in a household, there is a good chance that other members of that household will begin using themselves. Leaving aside the damage caused by ice use, one of its most devastating effects is the user's redirection of all resources into getting the ice and using it. At some point, nothing is as important as the drug.

    This is truly a different epidemic. Unlike ebola or AIDS, there is a population that is so dependent on the source of contagion the ice that they can no longer act in their own interest. In fact, there are competing interests here: the interests of the general public, parents, law enforcement on one hand, and the interests of the methamphetamine users and distributors on the other.

    One approach to controlling epidemics of this type is protected residential treatment associated with successful and thorough education of the community in which the contagion lives.

    Something that hasn't been done well in industries, cultures and communities is to bring everybody's level of understanding about drug dependence to a point where they can recognize and successfully direct the start of intervention. One major local employer is developing a proposal to ensure that all managers, and ultimately all employees, will know how to recognize and manage drug-use sicknesses in their colleagues. It is hard to grow crops in infertile soil, I understand. Something similar is true for addictions.

    There are treatments that work, and the development and improvement of those treatments is the aim of medical research. There is a good chance that medications will be available within the year that have an impact on craving and on the compulsion to use ice. New techniques are being developed to suppress the impulses that drive use, at the same time that researchers such as Dr. Linda Chang are demonstrating that the ice-sickened brain can heal.

    In the meantime, understand that existing treatments work, but they commonly require lots of repetition and slow, stepwise progress. Families can attend programs such as Nar-Anon and Al-Anon to effectively deal with effects of the illness on the family; at least one community treatment center offers free family support sessions.