In 2016, news reports warned the public of an opioid epidemic gripping the nation.
But Madeline Vaughn, then a lead clinical intake coordinator at the Houston-based addiction treatment organization Council on Recovery, sensed something different was going on with the patients she checked in from the street.
Their behavior, marked by twitchy suspicion, a poor memory and the feeling that someone was following them, signaled that the people coming through the center's doors were increasingly hooked on a different drug: methamphetamine.
"When you're in the boots on the ground," Vaughn said, "what you see may surprise you, because it's not in the headlines."
In the time since, it's become increasingly clear that, even as the opioid epidemic continues, the toll of methamphetamine use, also known as meth or crystal meth, is on the rise, too.
The rate of overdose deaths involving the stimulant more than tripled from 2011 to 2016, the Centers for Disease Control and Prevention reported.
But unlike the opioid epidemic -- for which medications exist to help combat addiction -- medical providers have few such tools to help methamphetamine users survive and recover. A drug such as naloxone, which can reverse an opioid overdose, does not exist for meth. And there are no drugs approved by the Food and Drug Administration that can treat a meth addiction.
"We're realizing that we don't have everything we might wish we had to address these different kinds of drugs," said Dr. Margaret Jarvis, a psychiatrist and distinguished fellow for the American Society of Addiction Medicine.
Meth revs up the human body, causing euphoria, elevated blood pressure and energy that enables users to go for days without sleeping or eating. In some cases, long-term use alters the user's brain and causes psychotic symptoms that can take up to one year after the person has stopped using it to dissipate.
Overdosing can trigger heart attacks, strokes and seizures, which can make pinpointing the drug's involvement difficult.
Meth users also tend to abuse other substances, which complicates first responders' efforts to treat a patient in the event of an overdose, said Dr. David Persse, EMS physician director for Houston. With multiple drugs in a patient's system, overdose symptoms may not neatly fit under the description for one substance.
"If we had five or six miracle drugs," Persse said, to use immediately on the scene of the overdose, "it's still gonna be difficult to know which one that patient needs."
Research is underway to develop a medication that helps those with methamphetamine addiction overcome their condition. The National Institute on Drug Abuse Clinical Trials Network is testing a combination of naltrexone, a medication typically used to treat opioid and alcohol use disorders, and an antidepressant called bupropion.
And a team from the Universities of Kentucky and Arkansas created a molecule called lobeline that shows promise in blocking meth's effects in the brain.
For now, though, existing treatments, such as the Matrix Model, a drug counseling technique, and contingency management, which offers patients incentives to stay away from drugs, are key options for what appears to be a meth resurgence, said Jarvis.
Illegal drugs never disappear from the street, she said. Their popularity waxes and wanes with demand. And as the demand for methamphetamine use increases, the gaps in treatment become more apparent.
Persse said he hasn't seen a rise in the number of calls related to methamphetamine overdoses in his area. However, the death toll in Texas from meth now exceeds that of heroin.
Provisional death counts for 2017 showed methamphetamine claimed 813 lives in the Lone Star State. By comparison, 591 people died due to heroin.
The Drug Enforcement Administration reported that the price of meth is the lowest the agency has seen in years. It is increasingly available in the eastern region of the United States. Primary suppliers are Mexican drug cartels. And the meth on the streets is now more than 90 percent pure.
"The new methods [of making methamphetamine] have really altered the potency," said Jane Maxwell, research professor at the University of Texas at Austin's social work school. "So, the meth we're looking at today is much more potent than it was 10 years ago."
For Vaughn, who works as an outpatient therapist and treatment coordinator, these variables are a regular part of her daily challenge. So until the research arms her with something new, her go-to strategy is to use the available tools to tackle her patients' methamphetamine addiction in layers.
She starts with writing assignments, then coping skills until they are capable of unpacking their trauma. Addiction is rarely the sole demon patients wrestle with, Vaughn said.
"Substance use is often a symptom for what's really going on with someone," she said.
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.