In working with addicts newly engaged in abstinence from methamphetamine use, I have found similarities to individuals exhibiting not a pattern of addiction, but rather a symptom cluster often associated with traumatic brain injury (TBI). Symptoms of either illness can be mild, moderate, or severe depending on the extent of the damage to the brain, regardless of whether caused by blunt force trauma or methamphetamine-induced neurochemical alterations. In both cases, some symptoms are evident immediately, while others do not surface until a period of time has passed after the injury or the termination of chemical use.
A person with a mild TBI might remain conscious or might experience a loss of consciousness for a few seconds or minutes. The person also might feel dazed or not like himself for several days or weeks after the initial injury. Other symptoms of mild TBI include headache, confusion, lightheadedness, dyskinesia, blurred vision or tired eyes, tinnitus, lethargy, insomnia, behavioral or mood changes (loss of interest in daily activities), and trouble with memory, concentration, attention, or thinking.
A person with a moderate or severe TBI might show these same symptoms, but also might complain of a headache that gets worse or does not go away, repeated nausea and/or vomiting, convulsions or seizures, hypersomnia, dilated pupils, slurred speech, weakness or tingling/numbness, dyskinesia, and/or increased confusion, restlessness, or agitation.
The DSM-IV-R lists among its criteria for amphetamine intoxication (292.89) pupillary dilation, nausea and vomiting, psychomotor agitation, muscular weakness, confusion, seizures, dyskinesia, dystonia, or coma. While the “high” of methamphetamine lasts an average of 8 to 10 hours, continued assaults on the brain and body bring about a variety of medical conditions found in malnourishment and dehydration. Methamphetamine addicts tend to be awake for days (four to five days in a row is not uncommon) and then “crash” for two to three days of fitful sleep. Repeated cycles circumvent the circadian rhythm, bringing about symptoms commonly found in mood disorders (flat affect, constricted range of emotions, various difficulties with executive functions of the frontal lobe, etc.).
Given the similarities in the two conditions, a successful method of dealing with methamphetamine addicts is to approach them from the stance from which one would work with a person with a TBI. In this article, I will suggest methods of intervention based on several characteristics found in individuals with both conditions.
Overcoming concentration difficulties
Many methamphetamine addicts enter treatment with a noted deficiency in short-term memory and concentration, or time on task. In traditional treatment, there is a large amount of reading (the Big Book, 12 Steps and 12 Traditions, etc.) and written assignment work (Steps 1 through 5, drug history, etc.). This will quickly overwhelm the client, increasing already underlying anxiety and agitation and potentially resulting in elopement or request of discharge.
Programs can consider a number of options here. Written assignments can be reduced in volume and rewritten if necessary, using a monosyllabic vocabulary and brief, closed-ended questions allowing for simple answers. Rather than asking, “What chemicals have you regularly used in the past six months?”, ask, “Did you use ______ in the past six months?”, allowing for “yes” or “no” answers. Follow with graduated scales of use: “1 to 2 times a week,” “3 to 4 times a week,” and so on. This can be processed verbally in individual or group settings. Make written assignments a set of talking points rather than an end in themselves.
As for the reading component, consider smaller assignments. Rather than “Read Chapter 1 by Friday,” a proper instruction would be “Read the first five pages by tomorrow, pages 6 to 10 the following day,” etc. The end product—completion of the task—is the same, but it is in smaller portions and acknowledges clients’ shorter attention span and impaired concentration rather than battling it. For those with more severe impairment, consider having assignments read to them and staff writing brief responses. Or simply verbally complete the assignment and denote it as such.
Addressing reduced impulse control
Walking hand-in-hand with increasing anxiety and agitation in individuals with methamphetamine addiction is lack of impulse control. This will be demonstrated in somewhat tolerable ways, such as verbal interruptions of others during group, attempts to dominate the discussion during family work, etc. But it also might involve more objectionable and disruptive behaviors in a program, such as shouting obscenities, sexual acting-out, etc.
Management of the behavior and its often underlying cause (anxiety) is achieved by controlling the environment and guiding the situation. Environmentally, stimulus reduction is a long-known and successful method of reducing acting-out behaviors. Programs should consider calm, indirect lighting; soft colors on walls; calm background music if possible; and staff members walking at a relaxed pace rather than hurrying to get somewhere. Programs have control of the physical environment, which sets much of the mood for both staff and clients.