Motivation and context of concurrent stimulant and opioid use among persons who use drugs in the rural United States: a multi-site qualitative inquiry.
R J Fredericksen, R Baker, A Sibley, A T Estadt, D Colston, L S Mixson, S Walters, J Bresett, X A Levander, G Leichtling, T Davy-Mendez, M Powell, T J Stopka, M Pho, J Feinberg, J Ezell, W Zule, D Seal, H L F Cooper, B M Whitney, J A C Delaney, H M Crane, J I Tsui
Author Information
R J Fredericksen: University of Washington, Seattle, USA. rfrederi@uw.edu.
R Baker: Oregon Health & Science University, Portland, USA.
A Sibley: University of North Carolina at Chapel Hill, Chapel Hill, USA.
A T Estadt: The Ohio State University, Colombus, USA.
D Colston: University of North Carolina at Chapel Hill, Chapel Hill, USA.
L S Mixson: University of Washington, Seattle, USA.
S Walters: New York University, New York, USA.
J Bresett: Southern Illinois University School of Medicine, Springfield, USA.
X A Levander: Oregon Health & Science University, Portland, USA.
G Leichtling: Comagine Health, Portland, OR, USA.
T Davy-Mendez: University of North Carolina at Chapel Hill, Chapel Hill, USA.
M Powell: University of Washington, Seattle, USA.
T J Stopka: Tufts University School of Medicine, Department of Public Health and Community Medicine, Medford, USA.
M Pho: University of Chicago, Chicago, USA.
J Feinberg: West Virginia University, Morgantown, USA.
J Ezell: Cornell University, Ithaca, USA.
W Zule: University of North Carolina at Chapel Hill, Chapel Hill, USA.
D Seal: Tulane University, New Orleans, USA.
H L F Cooper: Emory University, Atlanta, USA.
B M Whitney: University of Washington, Seattle, USA.
J A C Delaney: University of Washington, Seattle, USA.
H M Crane: University of Washington, Seattle, USA.
BACKGROUND: In recent years, stimulant use has increased among persons who use opioids in the rural U.S., leading to high rates of overdose and death. We sought to understand motivations and contexts for stimulant use among persons who use opioids in a large, geographically diverse sample of persons who use drugs (PWUD) in the rural settings. METHODS: We conducted semi-structured individual interviews with PWUD at 8 U.S. sites spanning 10 states and 65 counties. Content areas included general substance use, injection drug use, changes in drug use, and harm reduction practices. We used an iterative open-coding process to comprehensively itemize and categorize content shared by participants related to concurrent use. RESULTS: We interviewed 349 PWUD (64% male, mean age 36). Of those discussing current use of stimulants in the context of opioid use (n = 137, 39%), the stimulant most used was methamphetamine (78%) followed by cocaine/crack (26%). Motivations for co-use included: 1) change in drug markets and cost considerations; 2) recreational goals, e.g., seeking stronger effects after heightened opioid tolerance; 3) practical goals, such as a desire to balance or alleviate the effects of the other drug, including the use of stimulants to avoid/reverse opioid overdose, and/or control symptoms of opioid withdrawal; and 4) functional goals, such as being simultaneously energized and pain-free in order to remain productive for employment. CONCLUSION: In a rural U.S. cohort of PWUD, use of both stimulants and opioids was highly prevalent. Reasons for dual use found in the rural context compared to urban studies included changes in drug availability, functional/productivity goals, and the use of methamphetamine to offset opioid overdose. Education efforts and harm reduction services and treatment, such as access to naloxone, fentanyl test strips, and accessible drug treatment for combined opioid and stimulant use, are urgently needed in the rural U.S. to reduce overdose and other adverse outcomes.
