As the momentum was slowing in 2003, evidenced in part by fewer obituaries in the Bay Area Reporter,¹⁶ the medical community would deservedly celebrate the research accomplished and the antiretroviral cocktails now available. Many patients did not need to see their primary care providers every week or month, for now they could get back to their lives and decrease the frequency of their laboratory and clinic visits. My practice, however, became even busier. People who had been living with impending death for so many years now needed to face their own sense of guilt, loss, and symptoms of posttraumatic stress. These feelings, at times referred to as the Lazarus Syndrome, have been likened to the suffering of Holocaust survivors, people who watched their families and friends die and fully expected to follow, but instead were at once freed to a changed and lonely world [6]. A new picture was emerging, one which would begin to define the next chapter of my life at Stanford. The life-saving medications were reducing the number of cases of dementia, but the prevalence of the milder forms of cognitive dysfunction was increasing. Some were also suffering from lipodystrophy,¹⁷ leaving the affected feeling demoralized and exposed. Hypogonadism was not uncommon among the male patients, characterized by sexual dysfunction and depressed mood. Medications such as exogenous testosterone could help some with this condition. Many, however, were turning to “dealers” for relief. Patients found a treatment that gave them energy, increased their libido, improved their attention and concentration, and allowed them to feel pleasure, even if for a limited period of time. This choice, however, did not come without a cost.

During the period of 2003–2005, the use of methamphetamine was becoming more obvious at the PACE Clinic and, to a lesser extent, at the Positive Care Clinic. The drug was relatively inexpensive; however, many would obtain their supply in exchange for sex. For others, 20 dollars was the price for a “bag” containing approximately four “hits,” enough to keep some people high for several days. Our patients would present themselves to the clinic desperately wanting to sleep or escape the psychosis. Weight loss and poor dentition were not uncommon. A large number had lost their homes, jobs, and relationships, and many were facing criminal charges for drug possession or theft. I was amazed that these patients would show up for their appointments at all. Still, it was almost impossible to predict the demeanor and appearance of the methamphetamine-intoxicated patient. Some patients seemed calm and focused. The “tweaker” stereotype, however, accurately described many who were using the drug chronically. I would see psychomotor agitation as I attempted to make sense of their pressured speech, much of which was nothing more than verbal responses to internal stimuli. Their paranoid delusions were complex dramas involving the FBI, hidden cameras, spying neighbors, and perhaps their nosey psychiatrist secretly monitoring their behavior. Some had delusional parasitosis, convinced that their bodies were covered in bugs. Open sores on their faces and arms were common and evidence to them that the “bugs” were eating their flesh. The PACE Clinic has a small room with a microscope that the infectious disease doctors use to examine specimens. This microscope was now being used more frequently to look at the pieces of lint or clothing fibers that the patients believed were parasitic creatures devouring their skin.

Some patients would stop taking their HIV medications when they were on a “run.”¹⁸ Others would continue to take their medications but would also take other drugs, including gamma hydroxybutyrate (“GHB” or “G”), ketamine (“K”), marijuana, benzodiazepines, and MDMA (3,4-methylenedioxy-N-methylamphetamine, also known as “ecstasy,” “E,” or “X”). Because methamphetamine can cause erectile dysfunction, patients would also use phosphodiesterase type 5 inhibitors (including sildenafil, tadalafil, and vardenafil) and amyl (or butyl) nitrate (“poppers”), the combination of which can be lethal.

“Party and play” (PNP) was frequently the venue in which people, MSM¹⁹ in particular, would use methamphetamine. A typical PNP meeting would include two or more men using methamphetamine (and likely other drugs) and having sex. Because methamphetamine affects judgment, patients were presenting with evidence of engaging in unprotected sex, including higher rates of syphilis, gonorrhea, chlamydia, and Hepatitis C. New HIV infections were increasingly due to PNP methamphetamine use. In fact, almost one in three MSM who tested HIV-positive in 2004 said they had used crystal methamphetamine, representing nearly triple the rate of those MSM who had tested positive for HIV in 2001 [7]. As researchers were learning more about methamphetamine, the picture became increasingly alarming. Literature was confirming what we were learning from our patients: the drug not only stimulated arousal but also decreased sexual inhibition and led to the seeking of multiple sex partners and riskier sexual practices, including unprotected intercourse [8]. Those who did become infected with HIV were at an increased risk of depression and fatigue [9], symptoms that may have led patients to seek methamphetamine to feel better. Methamphetamine withdrawal could then lead to further depression and fatigue, and the user might then have sought more methamphetamine to combat those symptoms. Researchers during this period were also learning that long-term, heavy use of methamphetamine was damaging the neuronal brain cells already injured by HIV, leading to cognitive impairments, chronically altered mood states, and persisting psychosis [10].

Although the effects of methamphetamine were being discussed in our clinic’s case conferences as if it were a new player on the scene, the drug had been around for a long time. The first known synthesis of methamphetamine from ephedrine was in Japan in 1893, following the formulation of amphetamine in Germany in 1887 [11]. During World War II, branches of the German military used methamphetamine extensively. Eventually physicians in America would recommend amphetamines for weight loss, depression, fatigue, and hyperactive disorders. Cheaper forms of methamphetamine, synthesized in part from 1-phenyl-2-propanone,²⁰ would become available decades later and called “crank.”²¹ Production of crank decreased in the 1990s. New methods of synthesis, however, created a more potent drug in larger quantities. This product would be called Ice, Tina, Crystal Meth, or just meth. It could be smoked, slammed,²² snorted,²³ eaten, or “booty bumped,”²⁴ and synthesized in garages in small quantities or in remote facilities in larger quantities. Pseudoephedrine, a principal component in the production of meth, was being bought up in increasingly larger quantities from pharmacies [11]. We wondered if the effects we were seeing in the PACE and Stanford Positive Care clinics was limited to our region or if this pattern was nationwide.

Reports from the Arrestee Drug Abuse Monitoring Program showed that three California counties (Sacramento, San Diego, and Santa Clara) consistently ranked among the top five sites nationwide for the percentage of arrestees testing positive for methamphetamine at that time. In 2003, 36.9 % of San Jose adult male arrestees tested positive for methamphetamine at the time of booking [12]. Those male arrestees who admitted to using methamphetamine reported an average of 8.1 days per month of use of the drug [13]. In 2003, amphetamine/methamphetamine accounted for 47 % of adult admission to residential or outpatient treatment facilities in Santa Clara County [12].

What we were seeing in our clinics reflected the high rate of methamphetamine use in Santa Clara County. New infections could be attributed to meth use, not only in young MSM but also in older men who had practiced safe sex since the beginning of the epidemic and now had been introduced to Tina. For me it was most difficult to see those patients who had survived so much, including discrimination, bullying, rejection, unemployment, and the death of loved ones, now turning to meth. These vulnerable souls were hurting themselves, perhaps recreating familiar situations and feelings. Mood disorders were becoming more difficult to treat in those using meth, and some of our patients would ultimately commit suicide. Psychosis resulted, in part, from the surge of dopamine due to the methamphetamine. Antipsychotics were unable to block these dopaminergic tidal waves flooding my patients’ synapses. Best practices for treating methamphetamine abuse in the HIV population were still in their infancy. Approaches that held some promise included cognitive behavioral therapy and contingency management.²⁵ Medications, including some antidepressants and stimulants, were being investigated for their efficacy in reducing the urge to use methamphetamine. We were building a fairly good understanding of methamphetamine, including its effects on dopamine and the nucleus accumbens,²⁶ and yet we were feeling as vulnerable as our patients. Physicians were demanding evidence-based treatments. We wanted to see our patients thriving. We, however, were seeing our community becoming a public health nightmare.

“Dr. McGlynn, can you see the patient in Room 1?”

As the only psychiatrist for the PACE and Stanford Positive Care clinics, I was finding work becoming overwhelming, but my passion never wavered. The internists and infectious disease specialists were trained to focus on CD4 counts, HIV viral loads, and the latest antiretroviral medications, so they depended on me to help manage the emotional, behavioral, and cognitive changes they were seeing in their patients. Cases of sexually transmitted diseases and medication nonadherence continued increasing. Physical ailments normally seen in older adults were now affecting younger patients. When the body is in meth-induced sympathetic overdrive, the myocardium can only tolerate so much strain. As a result, ventricular enlargement and heart failure were being seen more and more in meth users of all ages, leading to permanent disability and loss of a sense of purpose. Chronic dehydration was leading to renal dysfunction and exhaustion. Although science was conquering HIV, meth was conquering the community. I was feeling completely impotent. My patients kept coming back to me asking for help, and yet it seemed that I—we—had nothing to offer.

In 2004 during a staff meeting, I vented my frustration and the need for more assistance. Our clinics did not have enough money to hire an additional psychiatrist. My coworkers wanted to help, so we decided to start meeting weekly to discuss meth and come up with ideas on how to understand the changing community and what we could do for them. We called ourselves The Crystal Meth Task Force, and the group included two social workers, a nutritionist, our pharmacist specialist, and me. After 2 months we were down to four members. The nutritionist dropped out after another month, stating, “I don’t feel like I’m useful here.” The remaining social worker, Niki Stalder-Skarmoutsos, a feisty and energetic young woman, and I moved forward on our own. I have heard Mozart’s String Duo No. 1 for Violin and Viola in G Major and knew that amazing music could come from just two instruments. We, however, had no money except for in-kind funding from the PACE Clinic and realized the only way we were going to make something of our task force was to get our hands on real money.

Pharmaceutical companies manufacturing antiretroviral medications have made a concerted effort to help the communities they serve. The first grant we applied for was from one of the larger companies, and we were awarded $3,000. This seed was just what we needed to get us motivated to seek out more funding. Santa Clara County Department of Alcohol and Drug Services (DADS) announced a Request for Proposals, seeking applications from county-based agencies targeting substance use in the region. Between the two members of the Crystal Meth Task Force, we wrote up a thorough proposal.