#24: Crystal Meth (Part 2)
COMMUNITY VOICE: Ben Anonymous | HEALTHCARE EXPERTS: Jona Tanguay PA-C, MMSc, AAHIVS; Luis Illades LMSW, CASAC | COMMUNITY REVIEWER: Anonymous | GUEST PRODUCER: Eric Kutscher, MD
SHOW NOTES
NOTE: this is part two of an episode series on methamphetamine use for gay, bisexual and queer men! Don’t forget to listen to part 1 if you have not and check out part one’s show notes!
Harm reduction
A range of things from behavioral modifications to having an overdose prevention kit to using drugs with someone else in case something bad happens
Meth and harm reduction can feel at odds. Why? Meth use comes with so many health risks that it can feel hard to make a dangerous thing sound safer
Harm reduction is an essential component of care for people using methamphetamines. Because there are such limited treatment options, staying safe and reducing the negative impacts of meth use is one of the main ways we can help people struggling with their meth use
patient centered and give back autonomy as possible,
Were you able to assert control in that way? So that's what I first like to start with is like behavioral sort of harm reduction.
Some harm reduction techniques as applied to meth use: (see below for links!)
Stay hydrated
Don’t forget to eat food!
“Meth mouth” is from dryness, not the drug itself. Using dry mouth gum can help prevent this (and rinsing after eating)
Safe injection supplies if relevant
Don’t share supplies, even straws (They can spread infectious diseases like hepatitis c)
Using a bubbler? Use filtered water, not something like gatorade - it's going to your lungs
Harm reduction tools discussed:
These links all have links to even more links!
There are medications that can help with cravings, decrease use, and support sobriety!
ASM guidelines with medication management list can be found here
Sometimes the study outcomes include a urine test without drugs, or going back to work, which doesn’t reflect some of the other real benefits that these drugs may provide
There’s therapy! Therapy! therapy!
Some light and uncomplicated topics (sarcasm!) that often come up in therapy: shame, compulsive behaviors, coping skills, disinhibitions, justifications, and cognitive distortions.
Meth gets in the way of therapy sometimes: “it's going to be very difficult to talk about your honest truths and your motivations and your goals and your history when someone's in psychosis”. True.
Chemsex! And Sobersex!
Meth use is often a part of gay/bi culture and a sexual aspect of that, especially the really intense connection and confidence people feel when having sex while high on meth
Let’s just quote our guest: “Sober sex is something that has been challenging for people who came of their sexual self in the crystal meth world. And so part of that is re acclimating to the reality and possibilities of sober sex. There is a certain maybe stamina. There are certain expectations. There are certain distorted realities that come into the chem sex world” (see why we just quoted!)
ABSTINENCE?! Because sober sex can be such an adjustment, there is a common approach to sex in early recovery that emphasizes a "no sex" approach or abstinence. Our guest noted how this can very easily be confused for homophobia or moralism. BUT (quoting again): “Sometimes it's important to take some time away from sexual activity in order to develop sexual values that are true, rather than merely just like a reaction to the environment that are like really based in somebody's wants and needs.”
TRANSCRIPT
Ben Anonymous: So yes, when you stop doing crystal meth, sex is probably going to be boring. Hang on. Like it might take more than a week for you to rewire your brain and what you think is sexy. What, what turns you on? If you're like certain kinds of sex that you like, you can do that when you're sober, if you like kinky sex or this kind of sex, you can do all of that when you're sober and you can do it better and you won't hurt yourself.
[QHP THEME MUSIC STARTS]
Gaby: Welcome to Queer Health Pod!
Sam: I'm Sam. I use he pronouns and I am a primary care doctor in New York City.
Gaby: I use she her pronouns, and I am a primary care doctor in New York City,
Richard: And I'm Richard, I use he and him pronouns, and I'm the director of LGBTQ clinical services at Bellevue Hospital in New York City.
Sam: And you're listening to Queer Health Podcast season three, episode six: methamphetamine use in gay and bisexual men, part two.
Gaby: Or: part two of our ~crystals~ episode.
[QHP THEME MUSIC ENDS]
Gaby: This is part two of a two part episode on methamphetamine use in gay and bisexual men. So if you missed part one, I'm feeling gracious today and I won't judge you.
Sam: Phewph!
Richard: She's so judgy.
Sam: Close call. You can listen to part one or part two out of order, but: we do recommend part one first, just so you can meet our guests and hear more about today's community voice, Ben’s, story in more detail and have more context for this episode.
Gaby: Today's episode will pick up where part one ended. We are gonna start by talking about the framework of harm reduction for methamphetamine use.
Richard: Then, we'll to talking about some medications that have been studied to help folks meet their meth use goals.
Sam: And then, ever so appropriately, we'll talk about therapy.
Richard: And we'll end with giving sober sex its moment. Sober sex is the concept we heard about from Ben at the top of the episode. In short, it's about how much of a barrier having sex without meth can be for folks pursuing sobriety, and also how you can still have fun and get pleasure from having sex after.
Gaby: When we say harm reduction, in this episode, we're talking about the ways that someone can decrease health risks that are associated with substance use without necessarily focusing on abstinence or sobriety.
Sam: Here's Luis Illades, a psychotherapist, social worker, and substance use counselor, who we met in part one.
Luis Illades: Harm reduction can be so many different things. Harm reduction can be like. Are you shooting up and do you have Narcan within reach so that you don't die? Are you using alone? Did you test your drugs beforehand? Do you know where the nearest emergency room is? There are so many different levels of harm reduction.
Sam: Meth's very real health risks, paired with a harm reduction approach, can feel very at odds with each other.
Luis Illades: I don't think there's any stretch of the imagination in which I would recommend that anybody use crystal meth, right? I've never, and in years of being both on the side of, "Go out and try drugs, kids. It's a liberation!" Right? And as a clinical provider who has worked specifically in substance use treatment, I don't think there's ever been a situation in which crystal meth has seemed liberating, useful, helpful, a source of information-gathering or experience-gathering. I'm sure someone somewhere can prove me wrong and find the logic to prove me wrong. But it's a pretty dark experience, right? Are there people who have dabbled in crystal meth and come out the other end without developing addiction? There's a handful, right? I've met a lot of people in my travels and in my work and in all the people, hundreds and hundreds of people that I met that have used crystal meth to varying degrees, there's a small handful of people that have tried it and come out the other end as a dabbler. But these are exceptions that if you're struggling with crystal meth, that's probably not you. So is it possible to dabble? Yeah, somewhere, maybe. But if you're having questions about how this is affecting your ability to connect with people, if this is causing you depression or distress, if you have ended up in a cadence with this drug that you find it difficult to get out of, it's probably not you. And far be it for me to call anyone an addict. But my hope is that we would have a conversation in which we can like, really look at the justifications that have come up and the stories that we've sold ourselves about what this is and ultimately have an honest conversation.
Gaby: In contrast to drugs like acid or ecstasy or cocaine, where folks may say like, "Yeah, sure, let's try it once. See if you like it." Meth just…isn’t that drug.
Sam: In part because that's the way meth can quickly rewire the reward and pleasure pathways and makes it hard for someone to recommend, "Yeah, sure, dabble once and report back."
Richard: But, you can use that same framing to actually take a more comfortable approach to harm reduction. It's so addictive, it's so easy to become problematic, that anything that lowers the risk is a good idea.
Sam: Dr. Eric Kutscher, our guest producer for these two episodes on meth, pointed out that harm reduction is an essential component of care for people using methamphetamines. Because there are such limited treatment options, staying safe and reducing the negative impact of health use is one of the main ways medicine can help people struggling with their meth use.
Gaby: Jona Tanguay, a physician assistant addiction medicine provider we met in part one of this episode points out that harm reduction works best when the patient defines their recovery.
Jona Tanguay: I think the most important thing, because I really try to be as patient centered and give back autonomy as possible, is, recovery is self defined. So for some people, recovery might be total abstinence. For some people, recovery might be like a three months drug holiday. And for some people, recovery might just be that they're going to have one day of rest, like a Sunday, where they don't use drugs. I really think it's more relevant to have the patient define problematic versus non problematic use. So in terms of problematic versus non problematic, again, it goes back to those DSM criteria, but those three major areas of like physical dependence, tolerance and withdrawal, cravings, and then social dysfunction. And maybe you're not using that to say let's get to zero meth use, but maybe you're getting to say, is your relationship with meth really what you want it to be? And how does it need to change to make it what you're looking for, Is it that we just have to fix these things with some harm reduction, some education, the reassertion of control? Or is it, likem total abstinence?
Richard: We want to highlight the way in which harm reduction here does not take the form of abstinence or "You should stop smoking meth or else," and instead centers on healthcare consumer definitions of problematic and non problematic.
Jona Tanguay: I think that a common thing we see is a slide from someone who is a weekend warrior, just partying on the weekends, like inviting into their life. Or if you say, before you go out, "I'm going to take 10 hits of a meth bubbler, and that's going to be it." Were you able to assert control in that way? So that's what I first like to start with, is like behavioral sort of harm reduction.
Gaby: Jona went on to talk about harm reduction techniques with meth that are focused on the physical health risks of meth and not just the problematic patterns and how using meth impacts other aspects of life.
Jona Tanguay: Talking about simple things like water, drinking lots of water when you're using anything that can harm your kidneys, like ketamine or meth. And meth mouth is not actually from the meth itself, it's from the dry mouth. There's actually a really interesting study out there from dentists, where they said actually if you modify the dry mouth, you won't get the dental decay – that’s not inevitable. So one of the other big things I tell people is get the dry mouth gum and Xylitol in it. Get the dry mouth lozenge. Make sure you're rinsing and make sure if you're eating sugar or anything like that, you're rinsing your mouth. Of course, the basic stuff of making sure that they're getting clean supplies, not sharing their supplies, including straws. Straws can spread hep C. I think that people always forget about that.
Sam: One of the other physical risks is lung damage, and Jona also had some harm reduction tidbits for that.
Jona Tanguay: In terms of the lung damage from even smoking as well, but especially with meth. A lot of the lung damage they found is actually just related to the fact that it is a super hot vapor. So water pipe, in terms of what it is for your mom, it's a bong. But a bong for meth looks a little bit different than a bong for weed because you're pulling the vapor in through water, it cools it a lot more, and so it's less damaging in that way to the lungs. And the other thing I always tell people is that more and more people use water pipes, they're not infrequent, but a lot of people love to flavor them because they don't like the taste of meth. And then I tell people “Gatorade wasn't meant to be put in our lungs.” The best thing you can do is get some purified water. Actually, it would be the best thing.
Richard: Jona also shared some information about how mixing poppers, meth, and erection medication increases the health risk potential for each of these medications, specifically because they all impact heart rate and blood pressure in dramatic ways.
Sam: Because meth will increase someone's heart rate and causes drastic increases in blood pressure that last beyond the euphoria and high of the drug, meth use has the risk of causing dangerous heart rhythms or arrhythmias and dangerously high blood pressure when mixed with other drugs that also impact heart rate and blood pressure.
Gaby: For more on poppers, check out our episode later this season about…poppers!
Richard: For more information specifically on risk reduction around these medical concerns, feel free to check out a few different websites Jona mentioned, including one they made called www.chemsexharmreduction.org.
Ben Anonymous: It's hard for me to say that you could use crystal meth safely. Can you use crystal meth like a gentleman? I don't know. Maybe you can. If you can, good for you. I see the people who try to do that and come into back into the rooms broken or who die. I know there's people out there. Who, sometimes I really want to say just to be open minded and cause I believe it. I know people who can do it. My friend so and so left the program and he uses sometimes and seems like he's okay. And then it gets bad and he comes back to the program. I'm sure there are people who use crystal meth a couple times a year. If they exist, good for them. People who can manage it. The other element is danger. You can't use crystal meth safely, in my opinion. Yes, it's a good idea. Don't go to a dangerous place. If you don't get it from a stranger, don't shoot up. Don't share needles. Absolutely. But, you can't use it safely. Come on. You're taking a risk. If you want to do it, go ahead, but Don't kid yourself.
Richard: Dr. Kutcher, the guest producer on this episode and an addiction medicine specialist, wanted to highlight that the goal of harm reduction is not to, quote, use crystal meth safely, end quote, as Ben describes. Rather, it's about helping people who are using crystal meth engage in care and decrease the complications and consequences of meth use on their health. So to be clear, Everyone I know who has used meth and had a problem with it has had to stop completely to get to the point of being deemed quote unquote healthy. That's unlike folks with alcohol or other substance issues who sometimes can dabble in a way that it meets and supports their health goals. While we absolutely support harm reduction and doing the things you can to take care of yourself, we wanted to be sure that was absolutely clear.
Gaby: And then on the flip side, though, abstinence worked for Ben. For many people who are struggling with substance use, the idea of quitting the substance completely seems really overwhelming and hard.
[TRANSITION MUSIC STARTS]
Gaby: And so the point is that any steps, small or large to improve quality of life and safety is a step in the right direction.
[TRANSITION MUSIC ENDS]
Sam: All right. So now that we've talked about harm reduction, let's talk about medications that help with meth use. Give me the highlights!
Richard: Even though as of the publication of this episode, none of these are FDA approved for their use in meth, that doesn't mean that they're not studied.
Gaby: Local and national guidelines for stimulant use disorder, which is the umbrella term that methamphetamine use disorder falls into do have recommendations about medications and dosing.
Richard: Who prescribes these? In some settings it's primary care, like us (whoops of excitement from Gaby and Sam) and (one final, celebratory whoop) okay, yes, I agree, but also beyond primary care there are folks like addiction medicine providers, psychiatrists, and often infectious disease doctors who work with populations who have lots of substance use disorders.
Sam: Before Jona told us about these medications, they pointed out how in a lot of these studies, the endpoints or outcomes that trigger a conclusion that the medication worked are urine drug tests that don't have meth in them, or someone's ability to go back work.
Gaby: Ooh. I love living in a capitalist society. Fun.
Sam: Exactly. So it's always good to know what the end point in the study is, because that helps us understand the ways in which these don't clearly capture how they may or may not benefit a patient.
Gaby: Alright, with that grievance off of our collective chests, here's Jona on a drug called mirtazapine, which also goes by her brand name Remeron.
Jona Tanguay: There's a lot of different medications that have use for meth use disorder, but the only medication that's been specifically studied in the context of chemsex is mirtazapine. And there were two studies, both showed a benefit. And both showed that even with crappy adherence to mirtazapine, there actually was a statistically significant drop in urine drug screen positive which is the outcome that people love, but again, I don't care about. But, you also saw positive things in the other outcomes about like depression and different sort of quality of life. So I really think that's important. I tell people, even if you're not going to use it every day to restore the sleep wake cycle, it's the best medicine to use for comedowns because it's the opposite of meth. It makes you tired. It makes you hungry, it makes you less anxious and it makes you less depressed.
Richard: Another option, which is a little more controversial but is data supported, basically works to replace methamphetamine with a prescribed stimulant, lisdexamfetamine, which is used for ADHD, and also known as Vyvanse.
Jona Tanguay: I call lisdexamfetamine the methadone of stimulants. It's long acting. You can't really use it other than the way it's supposed to be. Like, you can't really inject lisdexamphetamine. It doesn't work that way. You can't successfully snort it, either. So for those people that really want like those kinds of protections, it's there.
Sam: Dr. Kutscher, our community reviewer, noted that although there are studies to support the use of long acting stimulants for the treatment of stimulant use disorders, further research on the efficacy and safety of prescribed stimulants is needed. Prescribed stimulants can be a great option for some patients, but it's important to note that for better or for worse, many providers are hesitant to prescribe any off-label controlled substance to people with a substance use disorder. Consultation from an addiction medicine specialist or a psychiatrist can be very helpful in these cases.
Gaby: Jona also talked about some other drugs, which we will summarize really briefly for you.
Sam: Welbutrin, also known as bupropion, is another drug that is often used in depression treatment or to help folks quit smoking cigarettes.
Richard: Topiramate or topimax is another medication which is sometimes used in depression, seizure disorders, or migraines that, while it has a lot of side effects, does have data that it helps to reduce meth use.
Gaby: And then finally there's Naltrexone, which can be a shot taken monthly. It's known as Vivitrol. Or it can be taken daily as a pill. It's an opioid blocker that you may actually have heard of because it's used in opioid use disorder as well as alcohol use disorder to help reduce cravings there. But naltrexone also has a role in the management of stimulant use disorders like meth by reducing the cravings and the amount of meth use.
Richard: Dr. Kutscher pointed out that because stimulants including methamphetamine are becoming increasingly contaminated with fentanyl, naltrexone may also help to prevent an inadvertent opioid overdose from a fentanyl contaminated drug supply.
Sam: Dr. Kutscher also pointed out risk reduction techniques that speak to this specific issue. Access to fentanyl test strips and knowing how to read them, using any drug in the company of others in case you overdose, and having naloxone nearby, the overdose reversal nose spray, all on hand in case something bad like an overdose happens.
Gaby: To recap, the medications that we talked about are: naltrexone, lisdexamfetamine, bupropion, and mirtazapine. Kind of maybe topiramate and Voila.
Sam: That's the list.
[TRANSITION MUSIC STARTS]
Sam: It’s short, and there is a variable amount of data behind each drug in this specific context of meth use disorder, but there is data, and it's in guidelines, so know that if you're seeking medical care for stimulant use disorder, these may be some of the relevant options for your recovery. And so will therapy, which we will talk about next.
[TRANSITION MUSIC ENDS]
[SOOTHING CHIME NOISE STARTS]
Sam: (sighing) It’s time for therapy.
[SOOTHING CHIME NOISE ENDS]
Richard: So peaceful. We hit on this in part one, but we want to hear again from Ben, describing his realization that therapy and a 12 step program have different functions in recovery for many folks.
Ben Anonymous: I've been in therapy often in my life. I was in therapy before I came into recovery and I've been in therapy afterwards. I said to a therapist that I had before I got sober, and I stayed with her through some of my sobriety. I said, "Debra, why didn't you tell me to go to a meeting? Why didn't you suggest this to me?" And she said, "Ben, I told you over and over again, I suggested it over and over again that it might be a good idea." But therapy, I say therapy is not the 12 steps. The 12 steps aren't therapy.
Sam: Oof, more on Debra: who is she? Just how complicated a character? And what did she really say?
Richard: Missing the point…but like, I'm not, not interested.
Gaby: Here's Not Debra, but the therapist that we actually interviewed for this episode, talking about what someone seeking help with meth use may expect to get outta therapy.
Sam: I feel like Not Debra would be a great drag name, but here's Luis.
Luis: My hope when someone is seeking help in regard to their methamphetamine use strictly in the therapist and client relationship, is that there's a place of honesty and nonjudgment and support that can clarify justifications or like distortions in, like, what is being served by the use, right? And that can be more specific in discovering the power of maybe shame or the history in disinhibition with crystal meth and sex, right, and how those two are tied. It might be about developing concrete skills that would serve as countering like compulsive behaviors that are almost muscle memory or automatic, right? And stopping and pausing that moment and trying to assess what is alive and well in, in that moment that hasn't been paused previously. You might be ambivalent about your use and work with the therapist for, I don't know, an undetermined period of time and never stop using. That is an option. But I think looking honestly from a place where you're not justifying your actions and having another person involved in storytelling, in, in imagining outcomes, in developing coping skills and trying them on and coming back and reporting back about that, I think is very important.
Gaby: Okay, so a brief and totally uncomplicated list of topics that one could address in therapy includes distortions, justifications, disinhibitions, coping skills, compulsive behaviors, and shame.
Sam: Also, shame, compulsive behaviors, coping skills, disinhibitions, justifications, and cognitive distortions. Luis pointed out how the biology of crystal meth itself can also make it harder to engage in therapy.
Luis Illades: The comedown from crystal meth is brutal, right? And I've met a lot of different people that are coming in with a lot of different presentations, but sometimes we're talking about like psychosis and hearing voices or imagining things. It's going to be very difficult to like, let's talk about your honest truths and your motivations and your goals and your history when someone's like in psychosis or has been recently. Part of it sometimes has to be like kind of containment and like very clear direction until you can get to a point where you can have these types of conversations. So is it disruptive? Absolutely. Yes.
Richard: The long list of long list of heady topics and the biological ups and downs of meth use can make therapy super hard to engage with. Ben acknowledged the role of asking for help when starting to tackle these big hurdles.
Ben Anonymous: If you think you have a problem with crystal meth, I would say, ask for help. Ask for help. If you can do it on your own, do it on your own. If you can just stop. But if you can't, ask for help. And there's lots of things you can do to ask for help. You can go to a meeting. You can just show up. And the nice thing about meetings is you don't have to make an appointment. You don't have to pay for it. They happen at any time, all over the place. So you can go to a meeting. If you think you have a really bad problem, go to rehab. Just go. Just go. It's like we say, the war is over, you lost. Like, surrender! And then your life can get better. I would say ask for help. I would say don't feel ashamed. People feel ashamed about it. You can't do it by yourself. Some people think it's weak to ask for help. I think it's smart and it takes strength. I would say don't be ashamed if you think you have a problem. I'm an addict and I'm proud of it because of what recovery has given me and because I can help others and it's a part of who I am. So I would say ask for help, don't be ashamed.
Richard: In therapeutic settings, one of the highest hurdles is the way that meth use and the community it generates can become synonymous with someone's gay, bi, or queer identity, and their feeling of acceptance that they've desired from a time that they were very young and vulnerable and really craved this.
Jona Tanguay: I really think that link to sex and that link to culture is really important for people to understand because I think also, especially for providers who are perhaps less familiar with the LGBTQ+ community, they don't realize that drug use. All drug use has a culture to it, but especially in queer communities, there's a long history – there’s a cultural identity. And sometimes you have to realize that you're not necessarily just asking for someone to stop a bad habit. You're actually asking them to remove themselves from where they've placed themselves within a culture. And that means their practices, their beliefs, their network of friends, the way they talk, the underground lingo, et cetera.
Gaby: Luis spoke about how part of therapy is tackling internalized homophobia and stigma.
Luis Illades: I and some of my colleagues have discovered in working in recovery with gay men or MSM folk have been using crystal meth and are trying to reinvent their relationship to this is that vulnerability. And true communion with other people is really difficult when you're using, when you're used to the transactional and the hypnotic effect of crystal meth, right, and the sexual presence that delivers one to. And part of this is homophobia is particularly tied to crystal meth use. It never stopped and we have to relearn how to accept ourselves and join with other people in adulthood later on, right? That never stopped. So whether we learned it at 16 because we had accepting families and community, or at 35 for the first time after years of crystal meth use, like it's still there, right?
[CHIME NOISE]
Sam: Ah, therapy.
[CHIME NOISE]
Gaby: In both Part One and in this episode we've talked a lot about the way that meth use and sex are often one big, thorny – or maybe horny? – knot. In this last section, we're gonna focus specifically on sober sex, because for many people it's a huge hurdle in their recovery.
Ben Anonymous: For me using meth was almost always about sex. If I wasn't using meth because of sex, I was using my leftover meth cause I felt depressed and was tired and couldn't get to work. And yeah, when I stopped doing crystal meth that. I still, I wasn't rewired. It's what I was looking for was the thrill that came from drug driven sex. So I was kinda trying to have the drug driven sex without the drugs. It's the dopamine rush and the whatever, the sleaziness level of it, the horniness of it, the insatiable ness of it. Yes, there's that. But, I'll tell you, sober sex, it took me a while – I needed to get rewired. For me, it's much better. I'm present – I’m present! I'm enjoying the sex. There's not that euphoria, my head isn't spinning, but I'm present and I'm having sex with people who I like, who I think are attractive, who are nice to me, there's a fantasy about that. Crystal meth sex, chem sex, how great it is, and maybe sometimes it's nobody's dick is hard that they're on their phones looking for somebody else who's the next person they're paranoid, like cranky and they won't leave your apartment, stuff like that. There's something about, what about a real connection? I love that – that was what I was looking for. I was looking for that intense connection that came when I was high. But again, it was like, that, I never, I didn't, so I wasn't learning how to really have that. So yes: when you stop doing crystal meth, sex is probably going to be boring. Hang on. It might take more than a week for you to rewire your brain and what you think is sexy, what, what turns you on. If you're like, certain kinds of sex that you like, you can do that when you're sober. If you like kinky sex or this kind of sex, you can do all of that when you're sober and you can do it better and you won't hurt yourself. I have a friend who was high and he almost died. He perforated his colon. He had a colostomy bag for a while. It's there are risks when you're sober, but there are things that aren't going to happen. I promise you it's ultimately better. It's not the same thing, you’re not going to get those dopamine spikes. But, don't worry. Just hang on. Give yourself a break. Give yourself some time.
Sam: Ben mentioned sober sex, and for that many, sober sex feels, quote, worse compared to sex on meth. Luis elaborated on this.
Luis Illades: Sober sex is something that has been challenging for people who came of age or came of their sexual self in the crystal meth world, right? And so part of that is reacclimating to the reality and possibilities of sober sex, right? There is a certain, maybe, stamina, there are certain expectations, there are certain distorted realities that come into chem sex – world or routine or regimen, whatever you'd like to call it. And it's really hard to reacclimate to being present in a certain way for sex or being able to tolerate bodily functions or presence, weight gain, weight loss, like realistic bodily reactions to stamina, having feelings as anyone would in a sexual realm that may come up that have been blurred or erased or sidelined by crystal meth use. So there's a lot to tolerate because we're talking about mind, body, and spirit. And sometimes not only for the first time, but after years of kind of this Robocop sex, right? It's very difficult to tolerate and it's very easy to lose one's motivation when facing the sexual self that's based in reality, right? In, in human and the human experience. I hate to say limits because it's not about limits necessarily. It's more about like acceptance of self, of vulnerability, of feelings, of honoring yourself and your partner, of all the soft hues and like tender emotions involved in sex. That's honestly like one of the biggest jumping off points in recovery for crystal meth. Is that first sexual encounter or that first foray back into sexuality.
Richard: Because sober sex can be such an adjustment, there's a common approach to sex in early recovery that emphasizes a no sex approach, or abstinence. And since you know that we're a very sex positive group of people, here's Luis speaking on this thorny concept.
Luis Illades: A lot of times it's recommended not to have sex for the first few months – to get off all the apps and to abstain from sex. Which can be easily confused by people in the queer community with shades of homophobia or shades of like moralism, right? But far from it, because our hope is that people will return to a very gratifying sex life they get to determine based on their goals and wants and needs, not anybody else's. Sometimes it's important to take some time away from sexual activity in order to develop sexual values that are true rather than merely just like a reaction to the environment that are like really based in somebody's wants and needs. But when you're coming off of crystal meth and your defenses are way up, any suggestion or any boundary is going to met with resistance because it's going to be historical. I tried to get sober and I went and talked with this therapist or this counselor or went to a 12 step and they told me to stop having sex. Whose voice am I hearing in that? My father's, a priest's, a politician's, right? It's challenging.
Gaby: Let's bring it back to the ways that therapy can approach sober sex and the therapeutic role that this can have in someone's recovery.
Luis Illades: What are you going to do when you have your first hookup, right? Did you choose that person to spend with them and to invite them into your sexual space or did you just throw yourself into the apps? And what's going to happen when there's an awkward moment? How are you going to ground yourself in that moment and not give up ship and say, "fuck it, I'm relapsing"? There have been so many times that I had clients that were doing really well in their recovery and they had that first sexual encounter and it was human. It wasn't robotic or it wasn't like totally transactional and people have gone immediately gone out after that. These are experiences. These are not the rules. These are just like experiences that have happened, but people are very vulnerable in those states to relapse, to give up ship. I know that it's important to be honest about these stories and notice where the vulnerabilities are. But to anyone listening too, I would also say that you don't have to do this , right? There's something about the futility of repetition with crystal meth that seems impossible to get out of. And for every vulnerability that we're talking about and every difficulty that we're talking about, that's important to pay attention to. There are a lot of people who have recovered and that no longer have to use crystal meth in order to have a satisfying sex life, right? That stopped using crystal meth and did not lock themselves in their apartment out of isolation and hide away from the world, right? That made friends, that developed community that loved them. And most importantly, stopped living in a continuous cycle of like shame and reengagement with the drug. All of those things are entirely possible.
Sam: Oof, that is heavy.
Gaby: We'll let you rewind to play back Luis's insight into the cycles of shame and relapse and use that he was talking about. But we did wanna highlight the theme of possibility.
Sam: And to leave this on a more forward looking and optimistic note, we asked our guests to share some advice for folks listening, who may be thinking about entering recovery spaces. Here's Luis.
Luis Illades: The main things that I would want to leave a conversation with someone struggling with substance uses, specifically crystal meth is A) it doesn't have to be this way. Number one, if we're having a pyramid, at the very top is it doesn't have to be this way. There's a lot of love for you in the world, and my hope is that you can be delivered from a place where you can have a little more room to think and observe outside the cloud of crystal meth use, right? As a very emotional human being who works in recovery, my hope Is that you can show yourself to the world. My hope is that you can rejoin the world of the living and let yourself be loved and have the room to create a life that's meaningful for you that you want to live. You got one life to live. And I hope that you can squeeze as much juice out of that lemon as possible. So I hope you show yourself and I hope you let us get to know you. And I hope you can create experiences and memories that you'll remember because life's too short to be a zombie that's not connected to your feelings or your existence. That is the biggest crime of all.
Gaby: And here's Ben with the final word.
I used to think it was fun. Now I think it was escape from pain. There was euphoria there, but there's not joy. There wasn't joy. I remember, I was using – I went to this big notorious sex party at somebody's apartment. This daddy who had lots of crystal meth. And so, porn stars and hot boys were there. So I go to this party, I walk into this party and there's this gorgeous guy having sex with somebody else. And our eyes meet and he like disengages from that guy and comes over to me and we went and did the crystal meth thing. We had sex for 36 hours or whatever. What a thrill! That was as good as it got. That was as good as it got. This guy became a friend. I wanted to have sex with him more. He was going on to the next guy. It wasn't a very satisfying thing. About 10 years ago or so, my sister's neighbor was moving, they were selling their house. And my nephew said to me, “Uncle Ben, I think you should buy Bob and Martha's house.” That's a different kind of thrill, that my nephew wants me to be there. That lasts. So that's what's in my life now. That's what I get to be. I had a pretty good job when I got sober, but I was dragging this addiction along with me. The job was nice, but really what I wanted to do was to be in a room full of guys having sex and being sleazy. And my career really took off. And my life has become something that, that I never thought it could be. I'm not happy every single day. But if I have problems, I know what to do about it. And I've been sober for a long time and this program is still giving stuff to me. Sobriety is still giving stuff to me. It's an opportunity to live and to be maybe who I'm meant to be, to thrive. And I certainly wasn't doing that before I got sober.
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Gaby: QHP is a power sharing project that puts community voices in conversation with healthcare expertise to expand autonomy for sexual and gender minority folks.
Sam: Thank you to our community voice, Ben, for sharing his story, and as always, thank you to our healthcare experts Jona Tanguay and Luis Illades. We would also again like to thank our community reviewer, who chose to remain anonymous, but whose insight is still deeply appreciated. We would also like to of course thank Dr. Eric Kutscher for producing this episode and its companion, Part 1.
Richard: For more information on this episode's topic, check out our website at queerhealthpod. com.
Gaby: Help others find this information by leaving a review and subscribing to us on Spotify or Apple.
Sam: We are on social media, our handle is @QueerHealthPod reach out to us.
Richard: Thank you to Lonnie Ginsberg, who composed our theme music, and thank you to the Josiah Macy Jr. Foundation, who supported some of the tech we used to produce these episodes.
Gaby: Opinions in this podcast are our own and do not represent the opinions of any of our affiliated institutions. So even though we're doctors, please don't use this podcast as medical advice and instead ask your own healthcare provider.
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Richard: it's about how you can still have fun and get pleasure from having sex after.
Gaby: Allegedly.
Richard: It can be done.
Gaby: This is from the Monogamous Lesbian. Anyway… (laughter)