The last several years have seen a national rise in substance use among gay and bisexual men. In regard to crystal methamphetamine, the rates are high enough to be classified as an epidemic, according to Tom Wall, group facilitator of Lifestyles in Transition: A Group for Gay Men. San Diego’s ratio of users is growing at roughly the same rate as in New York, Los Angeles and San Francisco, and is also developing into a huge problem in Hawaii, Wall said.

A 2003 random-catch survey conducted by Stepping Stone for a social-marketing campaign targeting substance use among San Diego’s gay and bisexual males found 13.9 percent had used crystal meth in the previous two months. Jim Zians, project director for UCSD’s Edge Research Study and evaluation consultant for the survey, ran an analysis of variance and found that the men in the study who had used meth practiced safe sex less often than the men who hadn’t.

“That matches what we’re seeing nationwide among meth users,” he said.

The survey, conducted three times between May and September, questioned 684 men who have sex with men (MSM) at various locations around San Diego about their substance use habits, including alcohol. In addition to meth use, the survey reported 10.9 percent had used Ecstasy in the last two months, 30.9 percent had used marijuana, 11.3 percent had used poppers, 7.1 percent had used cocaine or crack-cocaine, 7.2 percent had used GHB and 5.4 percent had used ketamine. Approximately 6.5 of every 10 men surveyed either “always” or “usually” practiced safe sex; figures Zians said are fairly typical among MSM.

“That’s a lot better than what heterosexuals are doing,” he said. “But it’s not good enough, given our prevalence rates. That means that almost four out of every 10 men who have sex with men are not practicing safe sex.”

The Edge Research Project conducted a survey among their participants, over 340 HIV-positive MSM, finding that the top reasons for using crystal meth were to enhance sexual pleasure and make finding sex partners easier.

“I find that with people who use crystal meth as their main drug of choice, there is specific things related to their use, and one of them is sex and the Internet,” Wall said.

Besides unsafe sex and its direct link to higher rates of sexually transmitted diseases, long-term crystal meth use can result in psychosis symptoms such as paranoia, hearing voices, visual hallucinations and mood swings.

“People on crystal meth over a long period of time become very paranoid and do a lot of damage to their relationships,” Wall said. “The way that I look at it is that crystal meth literally starts to close a person’s soul off. … You look into their eyes, but you can’t really see into their eyes. You can see into their eyeballs, but they’re completely closed off from their emotions.”

Wall noted that the emotional distance the drug creates is alluring for many gay and bisexual men, because it takes away inhibitions they may have about coming out or engaging in same-sex sexual practices.

“In the gay community, I think the reason it’s such an epidemic is because we’ve got people who, in general, have been trying to come to a place of accepting themselves, having lived in a very shameful society about being gay and lesbian, and then once they start coming out and if they start using drugs it just further internalizes the shame,” he said.

Backed by First Avenue Counseling Centre and other organizations in the region, Lifestyles in Transition offers an alternative approach for gay and bisexual male users who are not yet ready to give up the habit, but understand that drug use is affecting their life. Based on the harm-reduction model, the theory is that users can acknowledge their habit without the stigma or shame that often accompanies admission of addiction, and take safety precautions to reduce harm to themselves and others until they are ready to quit.

“What that means is, it’s not necessarily about people becoming abstinent and remaining sober, it’s about getting people in the door,” Wall said. “One of the first steps of intervention is to get them to start talking about their use – that they use, how come they use and what type of consequences that could possibly be having on their life.”

Programs like Alcoholics Anonymous and Narcotics Anonymous, which are abstinence-based, are largely successful for those who enter into them, Wall said, but a portion of users not ready to take that step need to find a middle ground. “I think there’s so much fear around going out and asking for support, or asking for help, or even saying that they do it – that’s why I developed this group.”

The harm-reduction model meets clients where they’re at, from new use to relapse, and works with what they’re willing to do. That can be as little as walking in the door and acknowledging that they use.

Wall’s only rule with his clients is that they don’t come to his office high. “Other than that, [I ask] ‘So you used again this weekend. What was around that?’ Having people look at it that way without thinking, ‘I’m bad because I used.’ I think that’s one of the biggest components of harm reduction.”

The continuum of harm reduction runs from excessive use, to managed use, to abstinence. The model is grounded in James Prochaska, John Norcross and Carlo DiClemente’s Stages of Change Theory, which follows a continuum from pre-contemplation, to contemplation, to action and finally to maintenance. Also incorporated into harm reduction is the Health Belief Model, originated by psychologists Godfrey Hochbaum, Stephen Kegels and Irwin Rosenstock, which developed a systematic method of explaining and predicting preventative health behavior, focusing on the relationship of health behaviors, practices and the implementation of health services.

Some in the recovery community are hesitant to accept harm reduction theory, seeing the practice of addiction “management” as threatening to the notion of sobriety and true recovery.

“It’s becoming more acceptable in San Diego,” Wall said. “Right now, the harm reduction approach is really huge in New York and San Francisco. … L.A. has kind of jumped on board. San Diego has been a tough community because we’re just a much more conservative city….”

Stepping Stone presented the harm reduction approach at a conference on crystal meth held in San Diego last summer, a sign that the model is beginning to gain mainstream acceptance, he said.

Wall’s business partner formed a harm reduction group targeting lesbians, and found that the majority of responses were alcohol-based. “She had no responses to the group at all, as far as gay female crystal users,” he said.

Stepping Stone just completed a survey of substance use in San Diego’s lesbian community, but those statistics have not yet been released.

The Methamphetamine Strike Force, located in North County, reported a 26-percent increase in meth-related deaths – in all communities, not just among MSM – in San Diego County between 2002 and 2003, as well as a 22-percent increase in meth-related arrests and a 6-percent increase in testing positive for meth when arrested. l