People who use drugs (N = 144) were recruited March 2018-April 2019 using participant-driven sampling.¹⁷ Seed participants were recruited from local syringe service programs and given 3 “referral coupons” to distribute in their social network. Eligible referrals were enrolled and provided 3 coupons to invite their peers, and so on. Surveys regarding substance use, sexual and injection risk behaviors, and treatment and service utilization history were administered by study staff (ie, peer support specialists, research assistants) using tablet computers. Participants received an honorarium of $25.

July to September 2018, interview participants (N = 52) were recruited by peer support specialists at the syringe service program, outdoor field locations, and by direct invitation to the small number of individuals participating in the survey during interview recruitment. To reach service-seeking and non-service-seeking populations, the team selected locations identified by survey participants as frequented by substance-using populations. Interviews were conducted in semi-private or private locations (eg, public parks, mobile outreach van, community-based service locations). The interview protocol consisted of open-ended questions with probes exploring the same domains addressed by the survey. Interviewers were 4 research associates/assistants with training in qualitative data collection, experience interviewing people who use drugs, and backgrounds in social work, anthropology, developmental psychology, and public health. Before recruitment, the team jointly completed an interviewing skills refresher and completed mock interviews. Participant demographics were monitored for variation in gender and age during recruitment. After 2 rounds of interviews, the team determined that saturation had been attained. Participants received an honorarium of $50. Interviews, lasting approximately 60 minutes, were audio-recorded, transcribed, and uploaded into NVivo software (version 12.1) for analysis.

We used descriptive statistics to report survey responses of participant characteristics. We used thematic analysis with a semantic, inductive approach to analyze the interviews.^18,19 We read and familiarized ourselves with the data to create the initial codes and used an iterative process to refine the codebook. Two team members (RB, CP) coded the remaining transcripts independently, using the NVivo memo function to track questions for discussion. We met regularly to assess consistency in coding and resolve discrepancies. Coded data were then grouped into emergent themes.

Of 144 survey participants, the majority were male (56.9%), 30+ years (72.9%), and non-Hispanic White (79.9%). Seventy-eight percent used opioids in the past month; nearly all (96%) also reported using methamphetamine. Among those who indicated concurrent use, 56% noted heroin, 36% methamphetamine, 6% prescription opioids, and the remaining 2% some other drug (ie, cocaine, Buprenorphine) as their primary drug for getting high. We also asked about injection drug use. Out of 144 survey participants, 124 reported injection drug use in the past 30 days. Among those 124, 50% reported injecting both methamphetamine and heroin. Finally, 57% of those who injected both in the past 30 days reported simultaneous co-injection (ie, goofball).

The majority of interview participants were male (53.8%), 30+ years, and non-Hispanic White (see Table 1). Survey data provides a sense of prevalence of concurrent use; interview data provides insights into concurrent use. Three themes related to methamphetamine use emerged from interview data including (1) environmental characteristics support methamphetamine, (2) perceived benefits of methamphetamine, and (3) perceived consequences of methamphetamine.

Participants reported early exposure to methamphetamine; with many indicating first use in early or mid-adolescence, and most reporting they received methamphetamine from a friend or family member.

Participants described methamphetamine as a pervasive presence in their communities. They noted that, in comparison, heroin is harder to find and more expensive than methamphetamine. Because methamphetamine is “everywhere” and inexpensive, participants reported using it as a substitute for heroin.

While participants reported that both methamphetamine use and heroin use are stigmatized, they described greater perceived acceptance of methamphetamine use.

A common perceived benefit was the use of methamphetamine as a temporary coping mechanism for opioid withdrawal symptoms until participants could access opioids again.

Participants also reported using methamphetamine to cope with opioid withdrawal when they had trouble maintaining access to medications for opioid use disorder (MOUD) due to jail or titration.

While many participants used methamphetamine temporarily to cope with opioid withdrawal symptoms, some participants used methamphetamine in efforts to quit using opioids.

Other participants used methamphetamine to reduce frequency of their opioid use, which they perceived as more harmful than methamphetamine use. Participants expressed fear of physical dependence on opioids, withdrawal symptoms, overdose, and risk of other health conditions.

Some participants expressed belief that methamphetamine can prevent or reverse an opioid overdose due to the drug’s stimulant properties. When talking about a recent overdose experience, 1 participant reported adding methamphetamine to his heroin in advance in an unsuccessful attempt to prevent an overdose.

Another common perceived benefit of methamphetamine was improvement in ability to function. Ability to function emerged in the context of having enough energy to “get things done” as well as in reference to being able to attend to other life responsibilities. A few mentioned using methamphetamine to help them function in jobs that were labor intensive or required them to work long hours.

Participants used methamphetamine together with heroin because use of both–either sequentially or simultaneously–produced a more enjoyable high. Those that co-injected methamphetamine and heroin (ie, “goofball”), reported that the combination enhanced euphoria. Others noted that the energy they got from methamphetamine enabled them to enjoy the “buzz” from heroin longer.

Participants indicated that a negative consequence of using methamphetamine was risk of being discharged from MOUD treatment. One participant’s story highlighted how specific policies in treatment programs regarding abstinence can potentially increase risk of relapse.

While risk of fentanyl adulteration in heroin is well known, some participants reported experience with fentanyl in methamphetamine. Several reported symptoms (eg, sleepiness, nodding off) after using methamphetamine that could indicate presence of fentanyl. A few participants speculated that opioids are added intentionally in order to increase the addictive qualities and get people “hooked” more quickly.