J.R. McLain, a 52-year-old nurse in the emergency room at Providence Portland Medical Center on Northeast Glisan Street, says a typical night at work is vastly different than it was only two years ago.
Several times a night, he says, paramedics rush into the hospital with a patient strapped to a gurney. The man (just as frequently, it's a woman) is screaming—not a shriek of pain, but something frightened and enraged.
The patient is escorted to a private room, where two nurses and four security guards tie him to a bed with nylon restraints: thin red straps for his arms, and thicker blue ones for his legs. One staffer is assigned to each limb.
McLain, a registered nurse from Alabama with twinkling green eyes and a bushy orange beard that makes him look like a roadie for ZZ Top, is often tasked with speaking to the patient. In a typical case, the man calls McLain names—"Nazi," "fascist," "motherfucker"—and spits on the staff. It takes 20 minutes for an antipsychotic drug, Zyprexa, to calm him enough that all but one staff member can leave the room.
What's afflicting this guy and the hundreds of others with similar symptoms who were admitted to Portland hospitals in the past year? Too much meth.
When McLain first began working at Providence in 2010, he would see at most one patient per shift who was experiencing methamphetamine-induced psychosis.
Now, he says, he sees five to 10 such patients each night.
"Not a shift goes by where I don't experience, at the very least, a threat of violence, or someone posturing to hit me, or verbal abuse, or spitting, or grabbing, or trying to bite," McLain says.
His colleagues are routinely punched and kicked, too, he says. Last year, he watched an agitated patient grab a security guard by the neck and choke him until he passed out.
Every night, McLain reminds himself that the people arriving in the ER are more frightened than he is. "This is a human being who's having a crisis," he says. "This is not combat. This is not us trying to win. It's absolutely heartbreaking."
In the past five years, Portland-area emergency rooms have become the de facto detox centers for patients experiencing meth-induced psychosis. On the streets, the same symptoms are called "over-amping" or being "flailed out." Meth is sending users to the hospital—and straining what Portland's health care system can handle.
Providence spokesman Gary Walker told WW in an email that meth-related cases make up 1 percent of the hospital's emergency room visits annually.
"However, this population requires a much higher level of attention and care. Additionally, there is a higher degree of unknowns about potential behavior issues," Walker says. Providence is taking proactive steps to protect patients and workers, he adds, including a scale to assess dangerous behavior.
Bill Osborne, manager of Multnomah County's drug diversion courts, says he got used to seeing the same people cycling through the system.
In the past year? It's people he's never seen before. And they show a level of "agitation and aggression" that caught officials flat-footed.
"It's really awful to see," Osborne says. "It sometimes just feels like a tsunami of need happening that we're not able to meet."
The pressure is increasing. In January, the downtown sobering station run by Central City Concern abruptly closed after 35 years. While it was intended to serve patients who are drunk and need to sober up, Central City Concern was increasingly having to serve patients agitated by the use of stimulants like meth. The nonprofit said it was overwhelmed by stimulant drug users and decided to shut down.
In Portland, meth is more popular, more potent and cheaper than ever before. On the streets of downtown today, $5 will buy enough meth to keep a user awake for 72 hours, says Dr. Andy Mendenhall, chief medical officer at Central City Concern.
"Methamphetamines are one of the most reinforcing and mentally destabilizing substances known to man," Mendenhall says. "We have a combination of an apparently limitless supply at the street level of inexpensive, potent stimulants that are more potent than ever."
While local health officials and much of the media have understandably focused on the opioid crisis over the past decade, meth has, in the past three years, quietly returned to its place as a leading killer among narcotics. Data collected by state medical examiners shows that, while opioid overdose deaths are flat, overdose deaths from meth have increased rapidly.
In Multnomah County, meth-related overdose deaths rose from 10 in 2009, to 77 in 2018—increasing by 670 percent. Fatal meth overdoses are on track to supplant opioid deaths by the end of 2020 (see graph, below). Meth has already surpassed the deadliest opioid: heroin. In 2014, deaths from heroin in Multnomah County were more than twice the deaths from meth. By 2018, meth killed more than heroin.
While opioid deaths statewide peaked around 2011, deaths from meth-related overdoses have been climbing sharply. Meth-related deaths are on pace to eclipse those of all opioids (heroin and prescription painkillers combined) by the end of 2020.
Source: Oregon Health Authority
That's very different from what's happening in most places across the country. Federal figures say Oregonians rank second in the nation for frequency of meth use.
Mayor Ted Wheeler says Portland is part of a meth problem along the Interstate 5 corridor. "We see it on our streets," he says, "in hospital emergency rooms, in jails and in the growing list of Portlanders and their families who are suffering from this deadly drug."
In effect, meth is taxing a health care system that can't handle the burden.
"I feel powerless," says Dr. Paul Lewis, who retired in January after five years as the tri-county public health officer. "We're trying to prevent the house from burning. And I feel quite unprepared."
Over the past month, WW talked to more than a dozen public health experts and hospital workers. Most tell a similar story.
Meth's resurgence is a symptom of Oregon policy failures that can be traced back more than a decade. The state's leaders created the conditions for meth's popularity. If you wanted to ensure that meth made a comeback, you'd send people to sleep outside, create a market opportunity for dealers selling the most dangerous version of the drug, and remove criminal consequences for being caught with it. That's exactly what Oregon did.
And the burden falls on Portland's hospital emergency rooms.
"I deal with it every day," says McLain. "I'm not sure if the general public understands how big of a crisis it is."
The appeal of meth is simple: It provides a sense of euphoria, energy and superiority. It can also give the user a laserlike focus.
On the downside, meth use can bring about paranoia, delusion, jerking movements, agitation, insomnia and, sometimes, violence. The drug can kill you in a couple of ways, says Lewis.
"One is that it gets you so hyped up you get this thing called 'excited delirium.' And your brain just goes a little wild, and you die," Lewis says. Or, following prolonged meth use, a user will experience heart failure after having "revved the engine too long, too fast," Lewis says.
Related: Is there a safer way to use meth? Some Portlanders are trying to provide one.
Unlike opioid overdoses—for which the overdose-reversal drug Naloxone was developed—there is no FDA-approved method to reverse an overdose of methamphetamines.
Jon Hill, a 32-year-old Portland man with bright blue eyes who looks a bit like Maroon 5's Adam Levine, speaks with the slight Southern drawl of his native North Carolina. He first used meth 10 years ago in his home state, he says. He found it useful.
"In the beginning, it's fun," he says. "It's just like a button you can press that makes the bad shit go away for a time. All of a sudden, the most mundane things can make you feel better. That's how addiction starts: You have an instant 'off' button for feeling bad."
Meth was used during World War II to ward off sleep for soldiers and pilots. It's no surprise, then, that meth has become the drug of choice for Portland's homeless population. Experts say meth use among the homeless isn't for the high that might come with it; it's a method of survival.
"We hear many stories from many people about wanting to stay safe and alert at night, and meth being a way to help them do that," says Lewis. "It's not a crazy idea to think that the spike in homelessness could be one factor contributing to the more widespread use of meth."
Hill says he rarely takes too much meth. The last time he did was in April 2017, when he says he began "teetering on psychosis." He thought the FBI was following him, and he also had thoughts of suicide. Hill says he called his Alcoholics Anonymous sponsor, who told him he wasn't thinking rationally. The sponsor suggested he go to the emergency room, so he did.
"The first 24 hours I was there, I was completely spun out of my mind," Hill says.
When he arrived at Providence Hospital, he waited in line and told the receptionist he was having a mental health crisis. She called a security guard. "Immediately, I feel like a fucking criminal," Hill says.
The security guard took him to a safe room, which Hill describes as sterile and white. The security guard left him in the room by himself. For Hill, who was experiencing psychosis and also having thoughts of suicide at the time, the room felt like a "prison cell."
A doctor came to speak with him, and returned about every eight hours, Hill recalls. "As someone that's houseless, it's just kind of assumed you're there to somehow game the system," Hill says. "I think the guy just thinks I'm looking for a place to sleep."
Hill spent 24 hours in the room and didn't sleep the entire time, he says, because of the meth. After the first day, he was transferred upstairs to the psych ward, from which he was released two days later.
"They didn't set me up with a treatment program or anything like that," Hill says. "I immediately went back to what I was doing before I went in there."
Hill's experience is increasingly common: People taking too much meth are met with a health care system ill-equipped to handle their symptoms.
Until 2016, meth was a problem in Multnomah County, but not a crisis. That's the year 89 percent of heroin users in the county also reported using methamphetamines, as opposed to just 38 percent in 2010.
Then, meth in the county became more potent, and a whole lot cheaper.
This month, Portland police gave a presentation to the mayor and other city leaders. They warned that meth is the single most popular illicit drug in the city—mostly because you can get really high on a budget.
In 2000, a pound of meth was valued at $15,000, police say, and its purity was 60 percent, meaning the product was "cut" with other substances by 40 percent to stretch it.
By 2019, the price per pound dropped to $2,700, police say, and the meth they were seizing had a 90 percent purity.
"Over the last three years, we've been on an unprecedented run of meth coming out of Mexico and being pushed through the Pacific Northwest—not just Oregon," says Sgt. Erik Strohmeyer of the Portland Police Bureau's drugs and vice division.
"Our drug seizures, at least in our unit, reflect that. The price of drugs reflects that. I don't like using the word 'epidemic,' but I think meth is having a huge effect on the Portland metro area."
In the '90s—the last time meth in Oregon was a big story—the drug was home-cooked. In 2006, the state banned over-the-counter sales of the decongestant Sudafed, a key ingredient. Oregon was the first state to implement such a ban. Now it's one of two states that ban over-the-counter Sudafed sales. The restriction on Sudafed sales worked: Meth labs in Oregon virtually disappeared.
But drug cartels in Mexico saw a business opportunity: driving meth into Oregon up the I-5 corridor.
Oregon now ranks second nationally for methamphetamine use in the past year by people 12 and up, behind only New Mexico. The experts who spoke to WW for this story could not pinpoint why exactly meth use is so concentrated in the Pacific Northwest, though they suspect our proximity to Interstate 5 has something to do with it.
Oregon Senate Majority Leader Ginny Burdick (D-Portland) sponsored the bill that shut down meth houses. Despite the actions of the cartels, she says the law was successful because it closed the labs. "Many of these were in homes where children live," she says. "That's unacceptable."
Police data shows Portland's meth is getting more potent at the same time it costs less. Over the past two decades, the price of meth has decreased by 82 percent, while the potency has risen by 30 percentage points, to an almost pure product.
Jon Hill says he's never seen street prices so low. "It has gotten insanely cheap," he says. "People are able to do much more than they were able to do before."
Five bucks' worth of meth today? "That would get me a big enough shot that if I did it now," Hill says, "I wouldn't go to sleep until tomorrow night at the earliest."
Cheap, potent meth pushes more users into psychosis, says Osborne, the diversion courts manager. He's seen a rise in patients who are "dually diagnosed," meaning they have a diagnosed mental illness, as well as a substance use disorder.
"By and large, 90 percent of our clients are dually diagnosed, and the drug of choice is usually methamphetamines," Osborne says. "Methamphetamine seems to be the thing they need to push them into a full-blown psychotic episode."
Meanwhile, Oregon lawmakers passed a groundbreaking 2018 law that defelonized the possession of less than 2 grams of meth. Even before the law, Portland police slowly began making fewer arrests for methamphetamine possession, beginning in 2013. Arrests for meth dropped 25 percent over the most recent five-year period.
Those choices were aimed at reducing prison populations and racial disparities in arrests. It worked. But the policy change was also intended to divert users addicted to drugs into treatment instead of jail.
Many now end up in the ER instead.
Multnomah County District Attorney Rod Underhill, whose office led the effort to defelonize meth possession, says he expected more health care resources to tackle addiction—not less. "A reduction in resources and funding to those programs and organizations," he says, "is antithetical to the mission we have at the District Attorney's Office to help individuals addicted to drugs."
Oregon Attorney General Ellen Rosenblum sponsored the statewide legislation. (Disclosure: Rosenblum is married to the co-owner of WW's parent company.) Her spokeswoman says Rosenblum stands by the bill: "We agreed jail is not the best place for nonviolent drug-addicted individuals."
When Portlanders over-amp, police used to take them to the downtown sobering center. But it closed in January—in part because it couldn't handle meth symptoms. So now, police drop off users suffering from psychosis at one of three places: jail, the ER of a local hospital, or Unity Center for Behavioral Health in the Lloyd District.
When Unity opened in 2017, it was lauded as the one-stop shop for mental health crises in the county.
Sherrie Neff, a registered nurse, has been assaulted twice since she began working at Unity when it opened in 2017. In neither case was her assailant experiencing psychosis, but she believes both attacks were linked to meth.
Once, she says, a patient picked her up and threw her against a wall. The second time, a patient lurched forward to punch her. She dodged the punch, she says, but banged her knee badly. She had to have surgery and wound up missing work for several days.
"I can't even tell you how often I see meth when I do [blood work on patients]. It's unreal," Neff says. "When they're on meth, they're more apt to have hallucinations, and they can be more aggressive."
Those hallucinations can become particularly dangerous when health care workers attempt to help, Neff says, and the worker appears to the patient to be part of the hallucination. "They're going to do what they can to protect themselves," Neff says. "To them, it's real."
Neff remembers a patient who came into Unity—an attractive young woman—who was using meth.
"I said, 'You are ruining yourself. You don't see any damage, but it's coming,'" Neff recalls.
"She said, 'You could really stand to lose 10 pounds, and meth would really help with that.' This girl is taking meth to stay beautiful. You just never know why people are taking it. There's always a story behind it."
Brian Terrett, spokesman for Legacy Health, which operates Unity, says the number of patients intoxicated on meth hasn't significantly changed in the past three years: 1 in 7 Unity patients test positive for methamphetamines.
"We have taken a number of steps to support safety," Terrett says, "including holding staff safety huddles multiple times a day."
In situations where Unity is full, the facility directs patients experiencing acute psychiatric episodes to emergency rooms.
Neff fears emergency rooms can't handle the overflow from Unity.
"It's unfair to the emergency rooms because they're dealing with people who are in crisis, health-wise," Neff says of the capacity issues. "And then you bring in a person who is violent, they want instant gratification, and they don't know how to wait—their brain won't allow them to wait."
McLain, the nurse at Providence, says he regularly treats patients diverted from Unity. (He spoke with WW solely from personal experience and not as a representative of Providence.)
"Our beds are tied down with people who are sobering from meth. It results in backups in the waiting room," McLain says. "A person who is acutely psychotic on meth can hold an emergency department bed down for 24 to 72 hours."
If all three of Providence's psychiatric rooms are full, which McLain says happens nearly every night, the staff scrambles to convert a designated medical room into a safe room.
This means gathering everything that could be used to self-harm—monitors, cords, chairs, an oxygen tank, even the garbage can—and pushing it behind a set of brown accordion-style doors so the objects are out of sight.
"You lock it, get your garbage can out of there, and you're ready to go," McLain says. "Have you ever been hit in the face with a metal garbage can?"
Mayor Wheeler says he became "acutely aware" of Portland's meth problem when Central City Concern closed the sobering center. "Local emergency rooms face the same challenge," he tells WW, "which is why it's an extremely high priority of my administration to resume the services provided by a sobering center."
Lewis, the doctor who used to oversee public health for the tri-county area, says if Portland wants to stop the flood of over-amped patients in emergency rooms, officials should focus on the underlying social ills that make people turn to meth.
"Making sure no one is living in unsafe conditions might be the best way to address it," Lewis says. "It has nothing to do with methamphetamine. It has to do with basic living conditions. So big, big stuff. There's no pill."
McLain agrees. "The average person will blame the problem on the drug," he says. "Meth is just the symptom of a much larger problem."
McLain wants to remain an emergency room nurse for as long as he can. He wants to help people whom he believes were let down by Oregon.
And he wants to be present for what he's witnessing, even if it's painful.
When McLain gets home from work every morning, his ritual is to sit cross-legged on his porch and play a video game of golf, he says. It helps take his mind off of an adrenaline-fueled 12 hours. Then, when he gets in bed, he says, he spends 15 minutes thinking back on his day: what bothered him, what was traumatic.
"When I first started in ER nursing, I tried not to feel things," McLain says. "But that takes a toll on you."
The nonprofit Journalism Fund for Willamette Week provided support for this story.