In the 25 years since she snorted her first line of methamphetamine at a club in San Francisco, Kim has redefined "normal" many times. At first, she says, it seemed like meth brought her back to her true self — the person she was before her parents divorced, and before her stepfather moved in.

"I felt normal when I first did it, like, 'Oh! There I am,' " she says.

Kim is 47 now and has been chasing "normal" her entire adult life. That chase has brought her to some dark places, so we agreed not to use her last name, at her request. For a long time, meth, known commonly as speed, was Kim's drug of choice.

Then she added heroin to the mix. She tried it for the first time while she was in treatment for meth.

"That put me on a nine-year run of using heroin," Kim says. "And I thought, 'Oh, heroin's great. I don't do speed anymore.' To me, it saved me from the tweaker-ness," she says, referring to the agitation and paranoia many meth users experience, and how heroin, an opiate, calmed that.

Now, Kim has just finished addiction treatment for both drugs.

She was part of the last meth wave of the '90s, and now she's part of a new meth epidemic sweeping through parts of the United States, especially the West. Deaths involving methamphetamine are up. Hospitalizations are up.

Taking meth and opioids for a "synergistic high"

Researchers who have tracked drug use for decades believe the new meth crisis got a kick-start from the opioid epidemic.

"There is absolutely an association," says Dr. Phillip Coffin, director of substance use research at the San Francisco Department of Public Health.

Across the U.S., more and more opioid users say they use methamphetamine as well, up from 19% in 2011 to 34% in 2017, according to a study published in the journal Drug and Alcohol Dependence last year. The greatest increases were in the western United States.

That research suggests that efforts to get doctors to cut down on writing opioid prescriptions may have driven some users to buy meth on the street instead.

"Methamphetamine served as an opioid substitute, provided a synergistic high, and balanced out the effects of opioids so one could function 'normally,' " the researchers write.

It's kind of like having a cup of coffee in the morning to wake up and a glass of wine in the evening to wind down — or using meth on Monday to get to work and heroin on Friday to ease into the weekend.

Amelia says that's how her drug use evolved to include meth.

At first, drugs were just a fun thing she would do on the weekend — ecstasy and cocaine with her friends. Then, on Monday, Amelia would just go about her workweek.

"I'm a horse trainer, so I worked really hard, but I also partied really hard," she says.

Then one weekend, when Amelia was feeling kind of hungover from the night before, a friend passed her a pipe and said it was opium.

"I thought it was like smoking weed or hash, you know?," Amelia says now. "I just thought it was like that."

She says she grew to like the opium stuff and eventually contacted the friend's dealer.

"The woman said, 'How long have you been doing heroin for?' and my jaw nearly hit the ground," Amelia says. "I was just really, honestly, shocked. I was like, 'What? I've been doing heroin this whole time?' I felt really naive, really stupid for not even putting the two together."

Pretty soon, Amelia started feeling sick around the same time every day. It was withdrawal symptoms — a clear sign she was becoming dependent on the drug. Her weekend smoke became her daily morning smoke. Then it was part of her lunchtime routine.

"I just kind of surrendered to that and decided, 'Screw it,' " she says. "I'll just keep doing it. I'm obviously still working, I'm fine.' "

A heroin habit is expensive. Amelia was working six days a week to pay for it. Any horses that needed to be ridden, any lessons that needed to be taught, she said yes to because she wanted the money.

But bankrolling her heroin use was exhausting. One day, one of the women she worked with at the horse barn offered her some meth as a pick-me-up.

Meth is comparatively cheap these days. It became the thing that kept Amelia going so she could earn enough money to buy heroin.

"The heroin was the most expensive part," she says. "That was $200 a day at one point. And the meth was $150 a week."

This pattern lasted for three years, until Amelia discovered she was pregnant. As soon as her daughter was born, she entered a residential treatment program in San Francisco — the Epiphany Center — that would accept her and her baby.

"I was OK with being a drug addict," Amelia says. "I was OK with that being my life." she says. "But I wasn't OK with having kids and letting that be part of my life."

Rehab admissions on the rise for mixers of heroin and meth

Admissions to drug rehabilitation for heroin have remained steady in recent years in San Francisco. But the number of heroin addicts reporting methamphetamine as a secondary substance problem has been rising. In 2014, 14% of heroin users entering rehab in San Francisco said meth was also a problem. Three years later, 22% said meth was also a problem.

"That is very high," says Dr. Dan Ciccarone, a professor of family community medicine at the University of California, San Francisco, who has been studying heroin for almost 20 years. "That's alarming and new and intriguing and needs to be explored."

The speedball — heroin plus cocaine — is a classic combination, he says.

"It's like peanut butter cups, right — chocolate and peanut butter together," he says. "Methamphetamine and heroin are an unusual combination."

The meth and heroin combo is colloquially referred to as a goofball, Ciccarone adds, because it makes the user feel "a little bit silly and a little bit blissful."

For Kim, the methamphetamine use came first. Then she added heroin.

"I ended up doing both at the same time every day, both of them," she says.

For Kim, it was always about finding the recipe to what felt normal. Start with meth. Add some heroin. Touch up the speed.

"You're like a chemist with your own body," she says. "You're balancing, trying to figure out your own prescription to how to make you feel good."

Now Kim is trying to find that balance without drugs. She's been sober for a year. So has Amelia, the horse trainer. Her sober anniversary is the same as her daughter's birthday.

This story is part of NPR's health reporting collaboration with KQED and Kaiser Health News.

Copyright 2019 KQED. To see more, visit KQED.

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