Substance Use & Misuse

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“It’s Crazy What Meth Can Help You Do”: Lay

Beliefs, Practices, and Experiences of Using
Methamphetamine to Self-Treat Symptoms of
Opioid Withdrawal

Sydney M. Silverstein, Raminta Daniulaityte, Kylie Getz & William Zule

To cite this article: Sydney M. Silverstein, Raminta Daniulaityte, Kylie Getz & William Zule
(2021) “It’s�Crazy�What�Meth�Can�Help�You�Do”: Lay Beliefs, Practices, and Experiences of Using
Methamphetamine to Self-Treat Symptoms of Opioid Withdrawal, Substance Use & Misuse, 56:11,
1687-1696, DOI: 10.1080/10826084.2021.1949612

To link to this article: https://doi.org/10.1080/10826084.2021.1949612

Published online: 19 Jul 2021.

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Substance Use & Misuse
2021, VOL. 56, NO. 11, 1687–1696
https://doi.org/10.1080/10826084.2021.1949612

ORIGINAL ARTICLE

“It’s Crazy What Meth Can Help You Do”: Lay Beliefs, Practices, and
Experiences of Using Methamphetamine to Self-Treat Symptoms of Opioid
Withdrawal
Sydney M. Silversteina, Raminta Daniulaityteb, Kylie Getzc and William Zuled
a
Center for Interventions, Treatment, and Addictions Research/Department of Population and Public Health Sciences, Wright State University
Boonshoft School of Medicine, Dayton, Ohio, USA; bCollege of Health Solutions, Arizona State University, Phoenix, Arizona, USA; cWright
State University, Dayton, Ohio, USA; dCenter for Global Health, RTI International, Durham, North Carolina, USA

ABSTRACT KEYWORDS
Background:  Across the U.S., methamphetamine use is expanding among people who use illicit opioids Methamphetamine;
(PWUIO). Motives for methamphetamine use must be contextualized within the experiences of PWUIO, opioids;
who may use methamphetamine not only to achieve euphoria, but also as a tactic of self-management. polydrug use;
The overall aim of this study is to contextualize lay beliefs, practices, and experiences of methamphetamine self-treatment;
qualitative
use as a form of self-treatment of symptoms related to chronic opioid use among PWUIO in the Dayton
Metro Area of Southwest Ohio, an epicenter of the ongoing opioid crisis. Methods:  This paper draws
on two phases of interviews conducted with 38 individuals who use both heroin/fentanyl and
methamphetamine. This paper primarily analyzes qualitative data but includes supplementary
information from the structured interview component. Qualitative interview sections were transcribed
in their entirety and thematically analyzed. Results:  Participants described learning about
methamphetamine as a tactic to treat opioid withdrawal symptoms through social networks and
through personal experimentation. Many participants suggested that methamphetamine was helpful
in relieving exhaustion, alleviating some acute physical symptoms of opioid withdrawal, and
providing a psychological distraction, although some admitted that methamphetamine use could
incur additional health risks. To effectively use methamphetamine as a tactic of self-treatment,
participants emphasized the importance of timing and dosing. Discussion:  Among PWUIO in the
Dayton area, methamphetamine use as a tactic to self-manage opioid withdrawal must be studied
in relation to historical and evolving patterns of illicit opioid use and associated risks. More research
is needed to understand the long-term health impacts of this emergent practice of polydrug use.

Background and aims
Across the U.S., methamphetamine use is expanding among
people who use illicit opioids (PWUIO) (Centers for Disease &
Prevention, 2008; Ellis et al., 2018; Jones et al., 2019; Strickland
et al., 2019; Twillman et al., 2020). In 2018, methamphetamine
was the most commonly identified illicit drug found in law
enforcement drug seizures across the U.S. (DEA, 2020). Issues
of polydrug use are of particular concern in regions such as the
Midwestern US, already reeling from the impacts of the
“triple-wave epidemic” (Ciccarone, 2019) of pharmaceutical opi-
oid, heroin, and illicit, non-pharmaceutical fentanyl (NPF) use.
Studies of people who combine use of opioids and metham-
phetamines have identified several areas of concern, including
increased risk of overdose (Al-Tayyib et al., 2017; Carlson et al.,
2020; Giang et al., 2020), and the infection-transmission risks
associated with more frequent injection and needle sharing (Cai
et al., 2020; Meacham et al., 2018). However, while methamphet-
amine and opioid co-use presents additional health risks, PWUIO
may encounter incentives to use methamphetamine beyond simply
chasing euphoria. Indeed, motivations for methamphetamine use
among PWUIO are complex and multifaceted (Ellis et al., 2018).
Some studies have shown that similar to cocaine co-use
(Duvauchelle et al., 1998), methamphetamine is often used in
conjunction with opioids to produce a novel synergistic high
(Al-Tayyib et al., 2017; Ellis et al., 2018; Palmer et al., 2020).
Prior studies have found that some individuals with opioid use
disorder (OUD) may co-use methamphetamine to increase pro-
ductivity and energy (Ellis et al., 2018) and to stay alert when
experiencing homelessness (Fast et al., 2014). Methamphetamine
use may also be taken up and assigned new meanings in the
context of the symptoms and struggles of managing OUD.
A few recent studies conducted in the US have suggested
that some people with OUD may use methamphetamine
to temper their opioid use. Among a nation-wide sample
of people entering drug treatment, Ellis et al. (2018) found
that 15.2% of their sample mentioned using methamphet-
amine if opioids were not available, as a means of man-
aging opioid withdrawal symptoms. In rapid ethnographic
assessment of a treatment center in Washington state,

CONTACT Sydney M. Silverstein sydney.silverstein@wright.edu Center for Interventions, Treatment, and Addictions Research/Department of Population
and Public Health Sciences, Wright State University Boonshoft School of Medicine, 2555 University Blvd, Suite 200, Dayton, Ohio, USA.
© 2021 Taylor & Francis Group, LLC
1688 S. M. SILVERSTEIN ET AL.
López et al. (2021) interviewed a small group of patients
about motivations for polydrug use, and found that ratio-
nales regarding the co-use of methamphetamine and opi-
oids included strategies to decrease overdose risk through
substitution of methamphetamine for heroin, as well as to
mitigate the effects of heroin withdrawal. While both of
these studies suggest that methamphetamine may be used
as a tactic to allay the symptoms of chronic opioid use,
both studies draw on samples entering or enrolled in treat-
ment and provide limited insights into how these practices
may play out in the setting of everyday life, and within
particular risk environments. Further, little is known about
the practices and techniques of using methamphetamine
to self-treat or self-manage symptoms related to chronic
opioid use, how this knowledge spreads through commu-
nities of PWUIO, or how people who engage in these
practices conceptualize their subsequent risks. Through an
analysis of in-depth qualitative interviews conducted with
people who use both opioids and methamphetamine in a
region deeply impacted by widespread use of illicit opioids
and high overdose death rates, we aim to fill this gap in
understanding.
In the Dayton, Ohio metropolitan area, where this study
is based, methamphetamine use is increasing (OSAM, 2020),
particularly among PWUIO (Daniulaityte et al., 2020).
Methamphetamine-positive unintentional drug overdose
death cases increased from 14 in 2015 to 102 in 2017, and
most methamphetamine-positive cases have also tested pos-
itive for NPFs (PHDMC, 2018). The increase in metham-
phetamine use in the Dayton metro area comes amidst
continuingly high opioid-related overdose death rates across
the state of Ohio, which, in recent years, has had one of
the highest overdose death rates in the country (Kiang et
al., 2019; Ohio Department of Health, 2017).
To explore methamphetamine use in the context of an
ongoing epidemic of opioid use and overdose death, this
study builds on the framework of “drug, set and setting,”
which posits that drug use experiences are not predeter-
mined, but rather co-constituted by the pharmacological
properties of particular drugs or drug combinations, social
and cultural expectations and contexts, and individual atti-
tudes and circumstances (Zinberg, 1984). A highly potent
stimulant, the experience of methamphetamine’s psychoactive
effect is thus profoundly shaped by dosing and potency,
context of use, and a consuming body inscribed with its
particular histories, such as navigating physical and psycho-
logical demands of chronic opioid use, as well as accumu-
lated and embodied experiences of social stigma. Qualitative
research among people using both opioids and methamphet-
amine can help to tease out the complex and at times con-
tradictory meanings associated with methamphetamine use,
as well as the ways in which knowledge and techniques of
methamphetamine as a self-treatment modality are shared
and spread across communities of PWUIO. Here, we con-
textualize lay beliefs, practices, and experiences of the phe-
nomenon of methamphetamine use as a form of self-treatment
of opioid withdrawal symptoms in order to delineate pro-
cesses by which socio-cultural settings and contexts shape
both the motivations for drug use and the experiences of
drug effects.
Methods
This paper draws on data collected for a larger study on
methamphetamine use practices in an area with high prev-
alence of non-pharmaceutical fentanyl use. First, formative
stage, qualitative (Phase I) interviews were conducted in
August-October 2019, followed by Phase II interviews that
included structured and qualitative sections and were con-
ducted between December 2019 and March 2020. Phase I
interviews included a total of 20 participants, and Phase II
had 52 individuals. This paper reports data obtained from
a total of 38 individuals who participated in Phase I and/
or Phase II interviews and also reported recent use of her-
oin/fentanyl.
Phase I interviews
Phase I interviews were conducted with a sample of 13
individuals who met the following eligibility criteria: 1)
18 years of older; 2) residing in the Dayton metro area; 3)
use of methamphetamine in the past year. Phase I partici-
pants were recruited through an ongoing, longitudinal study
of individuals with OUD (Silverstein et al., 2019, Silverstein
et al., 2020) and through snowball sampling. Phase I inter-
views included a series of open-ended questions about drug
use patterns, overdose, and experiences with self- and formal
treatment. Interviews lasted approximately one hour, and
participants were compensated with a $30 gift card. Phase
I interviews were transcribed by a trained graduate research
assistant, and then coded and analyzed thematically by the
first author to identify common themes in descriptions of
methamphetamine and polydrug (opioid and methamphet-
amine) use experiences, motivations for using methamphet-
amine, and perceived health consequences. Preliminary
findings from Phase I interviews were used to help design
Phase II interview protocol. Open-ended questions in both
Phase I and Phase II protocols were similar, with Phase II
including more detailed questions developed from the pre-
liminary analysis of Phase I findings. Qualitative findings
from Phase I interviews are included in this analysis, as
they demonstrate the emergence of descriptions of meth-
amphetamine use as a strategy of OUD self-management
during interviews focused more broadly on patterns of and
motivations for methamphetamine use.
Phase II interviews
Phase II interviews included both structured and
semi-structured interview sections, although this paper draws
primarily from qualitative findings. Phase II interview par-
ticipants met the following eligibility criteria:1) at least
18 years of age, 2) live in the Dayton, OH metropolitan area,
and 3) past month use of methamphetamine. Phase II par-
ticipants included some of Phase I participants (key

informants), as well as additional recruits identified through
Craigslist ads, flyers posted in the community, and referrals
from other study participants. Eight out of 13 Phase I par-
ticipants returned for Phase II interviews. Phase I partici-
pants who did not participate in Phase II interviews but
who are included in this analysis were either unable to be
contacted or had stopped using methamphetamine by the
time of Phase II recruitment. The study was approved by
the Wright State University IRB. Interviews lasted between
60 and 90 min, and participants were compensated with $40
check or gift card.
The phase II interview protocol included a structured
assessment which collected sociodemographic and drug use
history data, and a number of questions on the motivations,
perceived benefits and risks related to methamphetamine
use that were developed on the basis on Phase I interview
data. The structured assessment was followed by a
semi-structured interview section, comprised of open-ended
questions that asked participants to describe first experiences
with methamphetamine, patterns of methamphetamine use,
experiences with methamphetamine and overdose, and expe-
riences using methamphetamine in conjunction with opioids
and/or while in treatment for OUD, as well as questions
about beliefs and practices related to methamphetamine use
in relation to self-treatment of opioid withdrawal symptoms.
Questions and associated prompts included: 1) Please
explain how and why you use meth and heroin/fentanyl
together? 2) Is using meth helpful to self-treat heroin/fen-
tanyl withdrawal symptoms? How have you used meth to
self-treat withdrawals? If so, can you describe your tech-
niques of self-treatment with meth (i.e. - how much and
how frequently do you need to use meth to fend off with-
drawal). What withdrawal symptoms do you typically expe-
rience? How does meth help alleviate them? 3) Have you
ever used meth to try and stop or cut down opioid use?
Please explain. Where you able to quit opioids? For how
long? How did it work?
All interviews were conducted in a private field office by
the first, second, or third author. Quantitative data were
entered into RedCap, and the semi-structured components
of all interviews were digitally recorded in their entirety.
Qualitative data analysis
All digitally recorded interviews were transcribed by the
graduate research assistants and checked for accuracy by
the first or second author. All identifiable information was
removed from transcripts, and pseudonyms were assigned
to participants. NVivo was used for qualitative coding and
data analysis. Transcripts were coded by the first or second
author using a coding schema that reflected questions
addressed in the interview protocol, as well as emergent,
in-vivo codes. After an initial set of thirteen interviews were
coded, the first and second author compared coding schema,
and agreed on a coding schema that organized findings
through descriptions of the local risk environment (setting),
beliefs about methamphetamine, its availability, inherent
risks and benefits, and participants’ preferred modes of
Substance Use & Misuse 1689
administration (drug), as well as a more detailed set of
codes related to the co-use of methamphetamine and opi-
oids. Authors 1-2 created a parent code on “methamphet-
amine and self-treatment,” and within this parent code
nested sub-codes for information about knowledge trans-
mission, personal experiences, timing and dosing, and symp-
tomology, as well as a separate sub-code for experiences
using methamphetamine to quit opioid use. The coding
system was tested out on additional interviews, and then
discussed by the first and second author during weekly
meetings in order to refine the codebook and standardize
coding procedures.
Once a coding schema was established, the remainder of
the interviews were divided between the first and second
author for coding. Once coding was completed, the first
author exported coded data from key nodes to explore line
by line to identify patterns, associations, concepts and expla-
nations within the data which were then analyzed in relation
to existing research, using iterative categorization (Neale,
2016). In keeping with the “set and setting” framework, the
analysis thematized several key domains for further analysis
(Braun & Clarke, 2006): patterns of social learning (how
participants heard about or learned that they could self-treat
with methamphetamine), personal experiences of metham-
phetamine use as a self-treatment tactic, as well as lay
descriptions of the pharmacology (how it works) and dosing
regimens that made this a viable strategy. Descriptive sta-
tistics of structured interview data were used to help trian-
gulate qualitative findings.
Results
Participant characteristics
Of the Phase I sample whose interviews are analyzed here,
8 of the 13 participated in the Phase II interview, and their
sociodemographic and drug use characteristics are recorded
in Table 1. The remaining 5 participants are not included
in the Phase II sample because they either stopped using
opioids or methamphetamine by the time of Phase II recruit-
ment, or we were unable to reach them to schedule a Phase
II interview. These participants included two white males
(Jim and Marco), ages 35 and 39, respectively, one African
American woman (Shay), aged 33, and two white women
(Topaz and Stormy), both 50 years old.
The Phase II sample (n = 33) contained 18 participants
who identified as female, and 15 who identified as male.
All of the Phase II sample identified ethnically as white
(Caucasian). Nearly all participants reported daily use of
heroin/NPF over the past 30 days, with the exception of one
participant who sometimes alternated heroin/NPF with
non-prescribed, pharmaceutical opioids (although he used
some opioid daily or near daily), and a small number of
participants who had spent some portion of the past month
in an inpatient detox center and/or jail. All but one of the
participants had at some point attended treatment for opioid
use disorder where they received buprenorphine, methadone,
or a Vivitrol shot. Participants recounted more diverse
1690 S. M. SILVERSTEIN ET AL.

Table 1.  Participant characteristics (Phase II, n = 33). While other motives were present, we focus our qualita-
Number/ Percent/ tive analysis on beliefs, practices, and experiences of meth-
Characteristic Mean Std. Dev. amphetamine use as a form of self-treatment of opioid
Socio-demographics withdrawal symptoms. We have organized the subsequent
Sex
Female 18 54.6% findings in line with our theoretical framework of Drug,
Male 15 44.4% Set, & Setting, reordered as Setting, Set, and Drug in order
Ethnicity to begin with a contextualization of these practices within
White, non-Hispanic 33 97.1%
their local context.
Age, years (Mean, Std.Dev) 37.93 8.34
Drug use characteristics
Age of first illicit opioid use (Mean, Std. Dev.) 19.8 (5.7)
Age of first methamphetamine use (Mean, 28.4 (8.6) Setting: Expansion of methamphetamine in the
Std. Dev)
Ever received medication for opioid use 30 90.0% Dayton area: ‘it’s everywhere in that short of time’
disorder (MOUD) treatment (buprenorphine,
methadone, or naltrexone/Vivitrol) According to participant recollections, a form of crystalline
Used heroin/fentanyl by injection most 24 72.7% methamphetamine most commonly referred to as “ice,”
commonly (past 30 days)
Most common mode of methamphetamine increased in availability around 2017, quickly saturating local
administration (past 30 days) drug markets. Topaz, a 50-year-old woman, was shocked at
Oral 3 9.1% the ubiquity of ice on the streets when she was released
Intranasal 4 12.1%
Smoke 6 18.2%
after a brief period of incarceration.
Intravenous 19 57.6%
Anal (“boofing”) 1 3% Meth is just, I mean, pow! It’s huge. Like, I went to jail and
Met DSM-5 criteria for moderate-severe 32 97% was in the [transitional] program, because I was locked up
methamphetamine use disorder for four months. And I came out, and I didn’t know a meth
Attitudes and practices of methamphetamine use for opioid dealer when I came in. And I came out, and it’s everywhere!
withdrawal It’s everywhere in that short of time.
Ever used methamphetamine to manage 26 78.8%
opioid withdrawal
Ever used methamphetamine to help quit 18 54.6%
Similarly, 35-year-old Marco, who had used opioids for
opioid use fifteen years at the time of his interview, noticed a steep
Believes methamphetamine use helps alleviate increase in the availability and use of methamphetamine
opioid withdrawal symptoms
Yes 25 75.8%
among local PWUIO:
No 5 15.2%
Neutral/no opinion 3 9% It [methamphetamine] was really prevalent, it just all of a sud-
Believes methamphetamine use can help quit den showed up out of nowhere in large quantities and basically
opioid use
didn’t have to pay for it, everybody had it. People were giving
Yes 21 63.6%
it away. It was just all over the place.
No 6 18.2%
Neutral/no opinion 6 18.2%
Other motivations for methamphetamine use
The novel risks imposed by NPFs prompted changes in
To enjoy the high 31 93.9%
To help with emotional problems 14 42.4% drug use practices and generated strategies to cease or mitigate
To get more energy 31 93.9% opioid use (Mars et al., 2018; Silverstein et al., 2019). In our
To balance out the effects of heroin/NPF 24 72.7% interviews, methamphetamine use emerged as one such strat-
To enhance sexual experiences 29 60.6%
egy. 36-year-old Tasha, for instance, theorized that metham-
phetamine’s popularity was lined to its potential to help
manage opioid use, or potentially reduce the risk of overdose
patterns of methamphetamine use, with a mean of 18.45
death. She noted that “a lot of people gave up heroin for meth
out of 30 days (SD 9.33) of use reported (Table 1).
and switched over. We want to get high, but we don’t want
The majority (n = 24) of Phase II participants reported
to die.” Without articulating the same urgency, Stacey similarly
intravenous use of heroin/NPF as their most common
theorized that the growing availability of methamphetamine
mode of administration but reported more variety in their
was linked to the region’s high rates of opioid use:
most common forms of methamphetamine use, including,
injection (19), smoking (6), intranasal use (4), oral admin- SMS: what would be your best guess for why it [methamphet-
istration (3), and anal administration (“boofing”) (1). Four amine] has gotten so popular lately?
reported transitioning from intravenous methamphetamine
Stacey: Well, a lot of people have done what I’m trying to do
use to alternate modes of administration after painful expe-
and use it to get off heroin. I know it helps me. I don’t crave
riences attempting to inject methamphetamine and missing it as much.
veins or developing abscess or blood infection, which they
specifically attributed to methamphetamine, and not opioid, Stacey’s comment is important for what it suggests not
injection. Participants reported a range of motivations for only about how methamphetamine is used among commu-
methamphetamine use, including to enjoy the high, to help nities of PWUIO, but also about how knowledge is shared.
with emotional problems, to get more energy, to enhance Eight participants who shared multiyear histories of opioid
sexual experiences, or to balance out the effects of heroin/ use reported never having an interest in trying metham-
NPF (Table 1). phetamine unless it was suggested to them or offered as a

means of managing symptoms associated with opioid
dependency.
Set: Beliefs about methamphetamine use for self-
treatment of opioid withdrawal
Finding out about methamphetamine as a self-
treatment strategy
Over half (n = 17) of Phase II participants described hear-
ing—through social networks of people who use drugs—that
methamphetamine could help manage opioid withdrawal
symptoms, or even help taper or cease opioid use. 24-year-
old Corey, for instance, heard on the street that using meth-
amphetamine was “the best way to get off of heroin,” while
44-year-old Tom noted that “countless people have told me
they’ve gotten off of heroin with meth.”
The notion that methamphetamine could be used as a
remedy to help manage opioid withdrawal symptoms
appeared to be a relatively new idea in the local commu-
nities of PWUIOs. It was actively debated and passed on
through social networks as a form of advice for people
struggling with the demanding nature of opioid withdrawal
symptoms. 36-year-old Carlos describes one such instance:
It was around the time my friend gave me that bag of shards
[methamphetamine]. I told her that I was doing heroin, and she
told me that I needed to get off of it. She told me to snort a
little bit of the shards and it will help.
Carlos confirmed that the methamphetamine helped her
reduce her heroin use, and also noted that she had read
similar stories on a popular web forum where tips on harm
reduction are often shared. One other participant reported
reading in a different online forum about methamphetamine
as a tactic for self-treatment of opioid withdrawals.
Social and peer networks spread ideas about metham-
phetamine as a strategy to manage OUD. However, more
than half of the participants (n = 23) discovered metham-
phetamine’s therapeutic potential in management of opioid
withdrawals through personal experimentation. Kim, a
45-year-old woman who had begun using methamphetamine
when she was 42, described how she came to understand
that methamphetamine could help her manage her
opioid use:
Well, to be honest I didn’t know I was doing it at the time. I
was on Suboxone [buprenorphine/naloxone] and I couldn’t get…
I couldn’t find any more Suboxone […] I was using meth at the
time and it was day three and I didn’t realize that I didn’t have
it the whole time. Like, I had been looking for it, but I didn’t
realize how much time had passed. So, my husband said that
it had been days. It happened accidentally and then I realized
that I could get off that shit [opioids] with it. So that’s what I
would do. It definitely prolonged it and then when I had that
much time under me, I figured that I could do it, I could make
it a day. So that was what I would do.
Through social networks, peer suggestion, and personal
experimentation, PWUIO in the Dayton area learned to
employ methamphetamine as a form of lay pharmacotherapy
to self-treat or manage OUD-related symptoms. The results
of this experimentation, however, were not uniform, and
Substance Use & Misuse 1691
reflected the specific contexts of both personal experiences
of opioid withdrawal and the particular techniques employed
in the use of methamphetamine to self-treat these symptoms.
Does it work? From speculation to personal
experiences
The majority of Phase II participants (n = 26) reported personal
experiences of attempting to use methamphetamine to self-treat
opioid withdrawal symptoms (supplemental data on participant
responses to structured questions on methamphetamine use
for OUD self-treatment are presented in Table 1). Marco, whose
opioid use averaged between, by his estimate, between a half
gram and a gram of heroin/NPF in a day, explained his belief
and personal experiences that methamphetamine was more
effective pharmacologically than many other drugs in helping
alleviate the symptoms of opioid withdrawal:
You’ll try anything to not feel when you’re going through with-
drawal. And meth is definitely the most effective thing I’ve tried.
Cocaine is misery, Xanax, misery. Meth kind of hits some of
the, you know, you’re still cold and not well but you’re a little,
there’s something, it gets you up and moving. Everything else,
you just kind of are like, can’t even raise an eyebrow.
Kim’s 27-year-old daughter, Marissa, also found metham-
phetamine use to be an effective tactic in managing opioid
withdrawal. When she began to feel the onset of withdrawal
symptoms, she turned to methamphetamine, noting that, “I
start getting the cold chills and I know that I am about to
be dope sick I’ll be like, alright I need to get some ice […]
It helps a lot.”.
A smaller group of five participants were less convinced
of its efficacy as a tactic of self-treatment. For example,
Topaz explained her skepticism about its efficacy in the
following manner:
Now, some people argue, and think the debate is still out on…
Okay, some people are saying, “Oh, you can [use] meth and
you can kick heroin.’ And I’ve known people who have done
it. I’ve known people who have done it! I don’t understand
that at all! That blows my mind because there’s no way, if I’m
dope sick, I don’t want to be up for, you know, five days or
whatever it is. That’s crazy to me.
Although skeptics such as Topaz acknowledged apparently
widespread belief regarding methamphetamine use for opioid
withdrawal, they positioned their own personal experiences
as outliers to these communal beliefs and emphasized how
individual’s experiences with each drug shaped future contexts
of use. In a similar fashion, when Stacey described how she
used methamphetamine to help manage opioid withdrawal
symptoms, she noted that it had the opposite effect on her
partner, Bob, and shared her understanding of individual
differences in how drugs are metabolized by each person:
Bob doesn’t like to [use methamphetamine for opioid with-
drawal] … Ice will make him sicker. Like this morning when we
didn’t have anything [opioids], I suggested doing meth because
it makes me feel better. It takes all the opiates out of his body
and makes him feel sicker. It doesn’t take all the opiates out of
my body because it makes me feel better.
1692 S. M. SILVERSTEIN ET AL.
The perspectives discussed in this section reference meth-
amphetamine use as form of lay treatment to temporarily
allay or mitigate opioid withdrawal symptoms. However,
over half of participants (n = 21) believed that methamphet-
amine could be used to help quit opioids completely, and
a smaller number (n = 18) claimed, at some point in their
drug use trajectories, to have tried or done this themselves.
Some long-term opioid users, such as 38-year-old Becky,
who had avoided stimulants in the past, began experiment-
ing with methamphetamine as their opioid use became more
problematic. At the time of her interview, Becky had only
started using methamphetamine the year before after a
friend suggested it could help her manage her opioid use.
I was doing heroin and I was trying to get off of it. So, my
friend kept saying to try it because she had kicked heroin with
it before. I was so scared to try it, and I mean I had to do a
whole bunch, but I ended up doing it and getting off of heroin.
Becky stayed off of opioids for nearly two years but had
gone back to using both heroin/NPF and methamphetamine
at the time of her interview.
Unlike Becky, 50-year-old Stormy had a more extensive
history of methamphetamine use in addition to opioids. She
had first used methamphetamine as a teenager to help her
through long shifts as an exotic dancer. In more recent
years, she had turned to methamphetamine for both the
euphoric feelings it gave her and to help manage her opioid
use. After a painful surgery to treat a series of injection-related
abscesses, Stormy claimed that she was able substitute meth-
amphetamine for opioids, and cease using the latter com-
pletely for a few months:
SMS: okay. Have you ever used methamphetamine to get your-
self off of heroin?
Stormy: yes
SMS: can you tell me about that?
St: I just used it all day long every day for four or five days.
After the four or five days, I wasn’t sick from the heroin
anymore.
Since all participants recruited for the study were cur-
rently using opioids and methamphetamine, personal expe-
riences with successful opioid quitting were generally short
lived. However, a minority of participants (n = 7) remained
wary of methamphetamine’s purported benefits in managing
opioid use. Despite potentially helping with withdrawal
symptoms, or even to cease opioid use entirely, they acknowl-
edged that methamphetamine could also create new patterns
of drug use and new health risks. Rae described one such
instance, in which methamphetamine helped her stop using
heroin, but presented her with a new set of problems:
R: I was homeless, and I had a job and I worked a lot. I didn’t
sleep hardly at all. I wound up losing my job because I was
hallucinating from being up for like, 15 days straight. But I
stayed clean off heroin for a little bit with the meth.
SMS: Oh, you did?
R: But then I had to stop doing the meth because it was making
me a little crazy, you know? Had to take a break because it was
having some effects on my health, my veins, shooting it in your
veins and it certainly can’t be good for them.
Similarly, 33-year-old Shay practiced reducing her opioid
consumption by substituting methamphetamine, which she
said would prolong the onset of withdrawal symptoms.
However, she worried about the consequences of metham-
phetamine use on her mental health, remarking that “in the
back of my mind, I’m wondering when I’m gonna’ go nuts,
you know? Because I already started out that way, so I don’t
need anything helping”. While the majority of participants
did acknowledge a certain usefulness in using methamphet-
amine to treat withdrawal and related symptoms, they were
also aware of the potential problems incurred by these prac-
tices. As Carlos noted, “typically all it does is drop one drug
for the other”.
The drug & how it works
Methamphetamine and symptomatology of opioid
withdrawal
Overall, participant attitudes about methamphetamine effec-
tiveness in helping moderate opioid withdrawal symptoms
were tied in with detailed discussions of how it worked in
terms of specific symptomatology and benefits. Participants
often described opioid withdrawal symptoms as extremely
debilitating, a conjunction of physical discomforts, anxiety,
and exhaustion. When discussing use of methamphetamine
to counteract withdrawal symptoms, four participants noted
that it was particularly effective for what they described as
“restless legs” symptoms of opioid withdrawal. 31-year-old
Tiffany, who began using both heroin and methamphetamine
a decade ago, enjoyed the euphoric feelings of both drugs.
However, her methamphetamine use had an alternate func-
tion. As she put it,
“I use it [methamphetamine], snort a line if I had no fetty
[NPF] or whatever because my legs just start running. I’ll have
restless legs and I’ll do meth and it takes it away. It’s crazy what
meth can help you do”.
A number of participants (n = 7) also described using
methamphetamine to self-treat more general feelings of mal-
aise incurred by chronic opioid use. The inertia created by
withdrawal symptoms could then work to prolong the symp-
toms themselves, making it harder to go out and obtain the
opioid drugs that could relieve the individual of suffering.
Methamphetamine was described as providing the necessary
jolt of energy that empowered someone in the early stages
of withdrawal to get up and get out. Stacey, for instance,
relied on day jobs doing yard work or cleaning houses, and
often had to make a smaller amount of heroin/NPF last
longer, if she could not immediately find work in the morn-
ing. In this manner, she came to depend on methamphet-
amine to help get her up and moving despite the early onset
of opioid withdrawal:
Mostly, when I’m going through withdrawal, I just have low
energy and don’t feel like doing anything or just lay around.
But when you do meth, you instantly get up and you know,
start moving around again. It gives you energy.

In another instance, Marco described how a shot of meth-
amphetamine got him out of the house and able to perform
a day of landscaping work:
I went downstairs and I’m like, I can’t. I can’t do it. I gotta’ get some
dope or something. He [friend] is like, here try some of this. I did
a big fat shot of meth and I was up! Loading the truck up with
the chainsaws, getting everything on the hitch. I never would have
been able to… I mean, the amount of energy I had was tenfold at
least. Like, I wouldn’t have wanted to leave the house.
While it is perhaps not surprising that methamphetamine
would work as an energizer to help counteract the inertia
and fatigue of impending opioid withdrawal, other partici-
pants described methamphetamine’s pharmacological benefits
to work psychologically. Participants such Shay noted that
using methamphetamine made them less mentally preoccu-
pied with impending sickness:
It will also keep me from feeling like I gotta’ worry about being
sick. Cause, you know, the whole sick thing is way further in
the future than we talk about, but the thought is further off if
I only have meth.
Three participants even described going a day, or even
multiple days without using heroin, because continuous
methamphetamine use distracted them from even thinking
about opioids or withdrawal. These participants noted that
methamphetamine altered their perceptions of time, keeping
them focused on particular tasks to the exclusion of all
other distractions and responsibilities. 35-year-old Kevin,
who had long history of opioid use and was intimately
familiar with the pain of opioid withdrawal, explained that
although methamphetamine alleviated some of the sickness
but also helped distract him from his suffering:
You do it [methamphetamine] right away, and you just get lost
in what you’re doing, and you forget that you’re sick. It does
actually take away some of the sickness. Then you do forget
that you haven’t done heroin in four days.
Timing, dosing, and quality
In the previous section, Kevin hinted at the importance of
timing in the perceived efficacy of methamphetamine to
self-treat opioid withdrawals, carefully tested out and cali-
brated. 55-year-old Gary gave a detailed description of the
timing necessary for methamphetamine to be effective in
postponing the onset of withdrawal symptoms:
If you wake up in the morning, you won’t want to do meth to
stave off withdrawal, okay? Because you’ll be instantly, you’ll
make your sickness worse. You gotta’ get your fentanyl in your
system first before you ever mess with the meth (…) During
the day, any time after you got the fentanyl and while you’re
still in your conscious waking state of mind and you start to
diminish from the fentanyl, anytime during that period you can
take that to stave it off an additional two or three hours. Because
generally when you start noticing the diminishing, you’ve got
an hour, an hour and a half and you’re gonna’ be getting dope
sick. But with the meth, it’ll hold it two or three hours and
it’ll keep the pains of withdrawal off of you.
As Gary and others noted, in order for methamphetamine
to work, one could not wait to be too far into withdrawal
Substance Use & Misuse 1693
or else the methamphetamine would make things worse
instead of better. Indeed, four out of the five participants
who had unsuccessfully experimented with methamphet-
amine as a form of self-treatment noted that their poor
experiences were likely a result of timing. 41-year-old Hope,
for instance, noted:
I got told that it does work but that you have to do it before
you start getting really sick. I was already sick for a day and a
half, then I got some, did some and it made it worse.
A small number (3) of participants qualified their asser-
tions that methamphetamine could be used to self-treat or
self-manage OUD with recommendations about quantity of
methamphetamine used. Hope, who did not have success
using methamphetamine to self-treat her withdrawal symp-
toms, noted that, for friends who had successfully used it,
“It takes ounces [of meth]. I mean, when I say they use it
to get off heroin, it takes a couple of weeks and they are
using ounces.” Tasha, who claimed that methamphetamine
had helped her to cease opioid use, described the amount
required for the technique to work, “You should probably
have at least an 8-ball [1/8 ounce of methamphetamine] a
day for at least 3 or 4 days for it to really help you.”
While timing and dosing were crucial factors in perceived
efficacy, four participants made further qualifications regard-
ing methamphetamine varieties, with two suggesting that
methamphetamine only helped with withdrawal symptoms
if it was cut or contaminated with fentanyl. These partici-
pants suggested that it was not the methamphetamine itself,
but rather the presence of an opioid, that helped to relieve
symptoms.
Discussion
Our findings build on a framework of drug, set, and setting
by applying it in the context (reordered as setting, set, drug)
of a specific polydrug use practice in a particular time and
place. We add to a growing body of literature that has
explored motivations for methamphetamine use among
PWUIO both in (Al-Tayyib et al., 2017; Ellis et al., 2018;
López et al., 2021) and outside of the United States (Noroozi
et al., 2018; Palmer et al., 2020). Like these studies, we
situate experiences of methamphetamine use within partic-
ular contexts shaped by the structural factors that produce
risk environments (Rhodes, 2002), as well as locally con-
structed and shared beliefs and strategies about how, when,
and why to use particular drugs to attain specific effects.
Within the particular context explored in this paper, we
demonstrate ways in which participants situate their meth-
amphetamine use within strategies to self-treat or self-manage
symptoms related to chronic opioid use.
In the context of increased access to methamphetamine
through shifts in drug market dynamics, communities of
PWUIO have acquired considerable knowledge, both from
practical experience and peer networks, on the dosing reg-
imens and particular combinations of drugs that prolong
euphoria and best allay the onset of withdrawal symptoms—a
system of knowledge and tactics known as “street
1694 S. M. SILVERSTEIN ET AL.
pharmacology” (Hunt et al., 1984). In our study, many par-
ticipants explained that methamphetamine helped to alleviate
the stresses and symptoms of withdrawal by giving them
energy and lifting them out of the funk of impending sick-
ness, or by distracting or taking their mind off worrying
about their next dose of opioids. However, they argued that
timing was crucial, and that methamphetamine worked to
manage or delay the onset of withdrawal symptoms if taken
preemptively, but rarely worked to counteract sickness once
it had set in. Dosing regimens were crucial to obtaining the
desired effects of methamphetamine as an antidote to opioid
withdrawals.
In contrast to predominant discourse emphasizing nega-
tive consequences of meth use, (Peterson et al., 2019; Roach,
2012; Weidner, 2009), participants in this sample often drew
upon it to help them cope with, or function through, the
trials of daily life as a person living with OUD, while simul-
taneously acknowledging the potential harms incurred by
its use. Our findings supports a growing body of scholarship
demonstrating the multiple meanings of methamphetamine
both within the milieux of people who use drugs (Fast et
al., 2014), and between consumer accounts and public dis-
course (Dwyer & Moore, 2013). As Fast et al. (2014) note,
methamphetamine use is understood as a survival strategy
for street-entrenched youth, but it simultaneously incurs
new forms of stigma on youth already dealing with multiple
forms of hardship. Similarly, participants in our sample
acknowledged that, even while at times an effective lay strat-
egy for the self-treatment of opioid withdrawal symptoms,
methamphetamine use could also incur additional harms to
their health. Further, the notion of methamphetamine use
as a self-treatment tactic may have helped to rationalize
emergent patterns of polydrug use. Methamphetamine use
carries its own sets of stigmas across multiple domains,
and my compound the stigmas that PWUIO must already
face (López et al., 2021). Qualitative research is important
for teasing out the multiple and at times contradictory
meanings associated with drug use practices within partic-
ular contexts.
Among our study sample, the materiality of heroin/fen-
tanyl use factored deeply into individual experiences of
methamphetamine use. The looming threat of withdrawal
(“dopesickness”) is an ever-present and overpowering con-
cern for people with OUD (Bardwell et al., 2019; Bourgois
et al., 2009; Sue, 2019), including those in our sample. This
pressing preoccupation drives people’s ingenuity and
resourcefulness to experiment and search for ways to avoid
or lessen withdrawal pain when they run out of their pre-
ferred opioids or seek to quit on their own (Daniulaityte et
al., 2013; Daniulaityte et al., 2019; Paul et al., 2020; Silverstein
et al., 2020). For instance, we have shown ways in which
lay knowledge of methamphetamine pharmacotherapy as a
means of self-treating symptoms related to chronic opioid
use was shared among networks of PWUIO facing common
challenges in the management of their OUD.
Methamphetamine use as a tactic of self-treatment or
self-management of opioid use suggests the importance of
social learning among marginalized communities such as
PWUIO (Becker, 1953; Waldorf et al., 1992), who face mul-
tiple structural barriers in accessing appropriate care (Luoma,
2010; Muncan et al., 2020; Paquette et al., 2018). While
participants in this study did not directly describe metham-
phetamine use as a strategy emerging from an inability to
access treatment, it was described as a strategy used in
attempt to cease opioid use completely, highlighting unmet
treatment needs that persist despite expanded coverage and
availability. These findings highlight an urgent need for
development of novel approaches to treatment, as well as
further to help attain more nuanced understandings of both
the structural and personal barriers that drive lay attempts
at pharmacotherapy with substances such as illicit,
non-prescribed buprenorphine or even methamphetamine.
Without diminishing the physical and psychological
harms of methamphetamine use, it is important to consider
the diverse motivations for PWUIO to use methamphet-
amine, particularly as they emerge as a lay tactic of
self-treatment of both withdrawal symptoms and OUD.
Individuals with OUD need accurate, non-stigmatizing and
culturally sensitive information delivered through harm
reduction organizations, treatment providers and outreach
workers to help facilitate understanding of medical infor-
mation on health-related impacts of methamphetamine and
opioid co-use. Treatment professionals may consider the
multiple motivations for polydrug use among people pre-
senting for OUD treatment, given a growing body of evi-
dence suggesting pathways between lay attempts at
self-treatment and formal treatment entry (Cunningham et
al., 2013; Monico et al., 2015; Silverstein et al., 2019, 2020).
That some PWUIO are purporting to use methamphetamine
as a tactic of self-treatment suggests that motivations to
cease or mitigate chronic opioid use are present, and this
should not be ignored. Even if the path to treatment or
recovery is long and winding, it is a path, and greater harm
reduction and support services can help to ensure that peo-
ple have a chance to continue their journey.
While emergent research suggests methamphetamine use
may impact retention in OUD treatment (Tsui et al., 2020),
greater knowledge and understanding of the complex moti-
vations for polydrug use may work toward improving treat-
ment outcomes. For instance, if PWUIO are chastised for
methamphetamine positive urine screens within a treatment
setting, it could discourage them from staying in treatment,
even if their methamphetamine use stems from situated
strategies for mitigating the impacts of chronic opioid use,
or assisting with titration. Treatment providers may want to
consider evidence of polydrug use as a starting point for
discussions of self-treatment practices—particularly the moti-
vations and logics for them—rather than justification for
punishment or termination of care.
This research had some limitations. Due to the relatively
small sample size, emergent thematic categories at times drew
on beliefs expressed by a small number of participants. More
research is needed to understand how methamphetamine use
may or may not be taken up as a form of lay pharmacother-
apy to self-manage OUD in other settings. Interviews were
coded separately and not dual coded/analyzed to test

agreement, although the first and second author met regularly
to discuss coding and data analysis. Nearly all of the sample
participants identified as white. While this not representative
of the Dayton area’s racial diversity (USCB, 2020), there is
some evidence that methamphetamine use is the Dayton area
is more common among non-Hispanic whites (Daniulaityte
et al., 2007, 2020). More research is needed to better under-
stand this form of polydrug use practice among minority
communities. Another limitation to this paper is that it draws
on the perspectives of people actively using both opioids and
methamphetamine, which would suggest that there was at
least some affinity for the euphoric feelings of both drugs.
This study many not be generalizable to broader populations
of PWUIO, who may be more reluctant to experiment with
methamphetamine both as a euphoric drug and as a tactic
to self-treat withdrawal systems.
This paper explored the beliefs, practices, and experiences
of PWUIO regarding methamphetamine as a tactic to
self-treat and self-manage symptoms related to chronic
opioid use. Local knowledge of the techniques and practices
of methamphetamine use as a form of lay pharmacotherapy
allow us to understand drug use practices as they take on
new and situated meanings and help us to generate more
empathetic and compassionate approaches to care and inter-
vention for an emergent community of people who engage
in polydrug use practices. However, motivations for meth-
amphetamine use are diverse, and our ongoing research
continues to explore the multiple motivations for metham-
phetamine use, and how both these motivations for, and
experiences of, methamphetamine use are shaped by phar-
macological, historical, social, and individual contexts that
in turn impact both drug use trajectories and health out-
comes. Longitudinal research is needed to better understand
the impacts of methamphetamine co-use on the trajectories
of illicit opioid use and associated health risks.
Declaration of interest
The authors declare that they have no conflict of interest.
The authors alone are responsible for the content and writ-
ing of the article.
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