Illicit stimulant use in the context of daily injectable opioid agonist treatment: a grounded theory study with patients receiving treatment for severe opioid use disorder in Vancouver, Canada

Background: For people with severe opioid use disorder not responding to first-line treatments, evidence supports the effectiveness of injectable opioid agonist treatment (iOAT), where patients inject pharmaceutical-grade opioids daily under the supervision of nurses. Outcomes include significant reductions in opioid use, crime, and improvements in health. However with no services offered for stimulant use disorder in the setting of iOAT care, studies have demonstrated only modest declines in illicit stimulant use (i.e. cocaine and amphetamines). This study was designed to investigate how patients engage in the use of illicit stimulants in the setting of daily iOAT care.

Methods: Interviews were conducted with 31 patients at the Crosstown Clinic in the Downtown Eastside of Vancouver (Canada), the first iOAT clinic in North America. Following a grounded theory approach, sampling, data collection, and analysis were conducted simultaneously. Interviews were audio-recorded and transcribed verbatim. Coding proceeded in three stages, open line-by-line to make analytic sense of data, focused coding to synthesize larger segments of data, and theoretical codes to specify relationships between categories

Results: Participants described engaging in a process of “self-managing” their use of illicit stimulants in the setting of iOAT care. This process had three interconnected stages, each with a shared focus on decreasing exposure to and engagement with illicit stimulant use. The first stage was ‘Distancing from the street environment’which reflected the separation from the physical setting of illicit stimulant use participants experienced when they acquired access to stable opioid medication in iOAT care. Here, participants were able to leave behind the daily hustle (e.g. sex work, theft, drug dealing), become connected with care, and develop broader personal goals. The second stage was “Practicing control”, where participants described strategizing to “moderate” their use of illicit stimulants, and finding meaningful alternatives to stimulant use (e.g. employment, hobbies). The third stage was ‘Mobilizing external resources’ reflecting the availability, use of and desire to be supported in their efforts to self-manage their use. Participants emphasized the desire for access to a social network with shared goals (e.g. support groups), and for access to a safe pharmaceutical supply of stimulants in order to support their self-management efforts. Engagement in the process of self-managing illicit stimulant use varied with participants’ personal and structural circumstances, and with the costs and consequences of stimulant use faced in the context of prohibition (e.g. health problems, overdose, criminalization).

Conclusions: Given patients’ daily contact with care for access to their opioid medication, iOAT offers a tremendous platform for the integration of additional services to support patients that use illicit stimulants. Participants’ desire for external support in their self-management efforts suggests the suitability and urgency of scaling up evidence based interventions, including the prescribing of stimulants such as dexamfetamine in the setting of iOAT care. Findings can further support clinicians in understanding patients’ evolving needs relating to the pursuit of stimulant use recovery in the setting of iOAT care.