Our sample included 21 individuals. One respondent was not asked the questions about medication for MUD and was excluded from the analysis, leaving an analytic sample of 20 (10 from Nevada and 10 from New Mexico). Half identified as women and half as men (Table 1). Median age was 34.5 (range: 23–70), 45% of the sample identified as white and 50% identified as Latinx. Nine people (45%) experienced homelessness in the past 6 months. All participants used methamphetamine, and 13 reported using other drugs in addition to methamphetamine (usually heroin). Thirteen participants had experience taking medication for opioid use disorder (OUD).

Table 1 Demographic characteristics (n = 20)

First, we describe participants’ perceptions of the benefits and drawbacks of their methamphetamine and other substance use, because these experiences inform how they think about and discuss the potential medication. Then, we describe participants’ opinions about and preferences for a possible medication.

Benefits of methamphetamine use

When reflecting on the benefits of methamphetamine use, nearly every participant indicated that they liked the energy and positive feelings that methamphetamine provides them:

Actually, [methamphetamine use] gets me more […] ambitious – you know what I mean? – to want to do something. (R4 F20 NM)

But if I have the meth, it really helps me focus. The best part about it is that I feel happy and I can focus. I can get paperwork done. I can write an essay. I can study. Without it, forget about it. Still to this day, forget about it. (R10 F30 NV)

Among those who also used opioids, participants also said methamphetamine helped them counteract the sedative effects of their opioid use.

Yeah. I used to use heroin and started using meth a little bit back. I like the way that the energy and the ability to get things done that it gives me that heroin really didn’t kind of little bit of the opposite effect where I feel like I can function better on the day-to-day (R2 M20 NM)

As described elsewhere [22], participants who were taking medication for OUD also discussed how methamphetamine counteracted the sedation of methadone and suboxone:

I get tired a lot because of methadone, I’m at a pretty high dose but there’s a reason for that. But [methamphetamine use] keeps me stimulated if I take a hit or two. It’ll keep me up all day for me to – like my energy, just stay going… (R5 F20 NM)

For some participants, methamphetamine use improved their overall social life and helped them overcome feelings of introversion. Participants experiencing homelessness described not being able to let their guard down around other people, indicating that it was dangerous to do so. Several participants reflected on how methamphetamine allows them to safely navigate social settings:

I’m a really reclusive kind of person. I don’t like talking to people like in crowds, nothing. I don’t like loud noises, nothing. Meth, it lets me go outside and lets me fucking interact. I don’t worry too much about out it. If I maintain [my methamphetamine use] right and do the right amount, it’s way more sociable. (R11 M20 NV)

But now, it’s like I have to be out there with people. [Methamphetamine use] makes it a little bit easier for me to be around so many people all at once because I’d never really like to be exposed but it helps you get our mind off of, you know. It takes your fear of being exposed and being around a lot of people and people paying attention to you. (R20 F40 NV)

Additionally, several participants discussed how methamphetamine helps them to escape difficult emotions and cope with past traumas:

I would say it helped me deal with my trauma, I guess. I mean it’s very escaping (R1 F30 NM)

R: [Methamphetamine use is] a coping mechanism for me to be able to feel something than nothing….I don’t do well with emotions. Emotions make me extremely vulnerable in my past issues. I’m just not ready to deal with yet, [methamphetamine use] kind of keeps me from having to really deal with those until I’m absolutely ready to… (R19 F40 NV)

Drawbacks of methamphetamine use

While nearly all participants reported benefits to their methamphetamine use, reports of drawbacks were not so universal; only around three-quarters of respondents reported drawbacks. When reported, drawbacks included: family problems, paranoia, hallucinations, poor physical health, and withdrawal symptoms.

Several participants discussed how methamphetamine use created complications with their family and loved ones. While some reported that using methamphetamine helped them navigate their parenting duties, others worried that their methamphetamine use may place children at risk through criminalization [e.g. “(my girlfriend) has kids. I worry about that. I don’t want either of us to get into any kind of trouble that might mess things up for the kids…” (R2 M20 NM)]. Others reflected on challenges such as conflict with partners while using methamphetamine.

Participants also described a wide range of mental and emotional drawbacks. Experiences of psychosis, paranoia, getting “freaked out”, and emotional turmoil were common. About a quarter of the participants reported seeing “shadow people”, hallucinations of spirits, monsters, or ghosts after being awake for too long while using methamphetamine:

I used to see what’s called shadow people and three monsters, like closet monsters. That’s when I know I’ve been up way too long. (R19 F40 NV)

Experiences with withdrawal symptoms were varied, with some participants reporting no issues while others described excruciatingly painful withdrawal symptoms (e.g. “The come down, when [the methamphetamine is] wearing off, it’s like worse than being sick from heroin.” [R6 M30 NM]). Many participants reported debilitating pain during withdrawal:

When you start coming off of meth, it feels terrible. Your body feels like broken. Joints hurt. You’re swelling, swelling. You know what I mean? It’s pretty intense. (R21 M30 NM)

Acceptability of medication for MUD

We now turn to a discussion of how perceptions about the acceptability of a medication are related to the perceived benefits and drawbacks of methamphetamine use.

Most participants indicated a willingness to try a medication, with many expressing enthusiasm for the potential therapy [e.g. “that would be freaking awesome!” (R4 F20 NM)]. Several were skeptical that such a medication could exist (despite our explanation that one did not currently exist) but indicated that they are open to trying anything that might help them reduce their methamphetamine use [e.g. “I feel at this point, I’m willing to try anything” (R1 F30 NM)]. Several indicated that such a medication would benefit their community more broadly.

Five participants indicated they would not be open to a medication. They indicated that they did not view their methamphetamine use as a problem [e.g. “I don’t consider it a problem” (R17 M50 NV)] and each reported zero or only one drawback to their methamphetamine use.

Medication preferencesFunctionality and energy—stimulant replacement therapy

As described above, most participants appreciated how methamphetamine provides energy and focus needed to accomplish important life tasks and take care of responsibilities. In alignment with this, respondents indicated that they would prefer a potential medication to provide similar energy and functional benefits:

I: What would you want that medication to bring? What would it need to do for you in order for it to be a replacement?

R: I think as long as to be able to stay energetic and keep that energy coming and being able to do things in life and yeah. Just have that energy, that kick to go with it and not to lose that. (R2 M20 NM)

As such, many participants articulated the desire for a licit stimulant to replace methamphetamine. Several explicitly identified prescription amphetamines (e.g., Ritalin, Adderall) as an ideal candidate. One participant, when prompted about a potential therapy, indicated that it already exists in the form of such medications:

I: If there is a similar type of program like a medication-assisted treatment for methamphetamine, what interest in that would you have?

R: There kind of is [such a medication]. I mean, [inaudible]. And if I could do it, yeah, I’d do it. Absolutely, I’d take Ritalin or something. (R10 F30 NV)

Part of this connection was related to participants’ understanding of how medication for OUD works, by replacing the use of an illicit opioid (e.g., heroin, fentanyl) with a pharmaceutical alternative (e.g., methadone, buprenorphine). For these respondents, replacing methamphetamine with a prescription amphetamine follows similar logic, by providing benefits without some of the drawbacks.

I: Given your experience with Suboxone… one of the things that [we hope to learn] through this study is some information [about] willingness for methamphetamine type of medications and treatment. What would be your interest or desire or non-desire to utilize something like that?

R: That’s an interesting question. I’d be open to maybe Adderall. That would be [inaudible] pharmaceutical. It seems to be pretty clean. I tried it before. It’s pretty nice. It helps. It’s just razor -- not razor focus, just focus without some of the drawbacks.I’d be open to it. (R13 M20 NV)

Preferred treatment scheduleDaily dosing—ritual and routine

Most of the participants willing to try a medication indicated a preference for a daily dosing schedule, which would foster a daily routine:

R: I think the daily [dosing schedule] would be cool. It just gives you something to do and actually gets you on a schedule because if you want to start living in the real world, you have to get up every day to go to work. So, it would start making you get up for something. (R9 F30 NM)

Several participants discussed how the moment of consuming methamphetamine and the onset of the drug is an important aspect of their use. Some discussed the ritual nature of drug use [e.g. “something I can look forward to, something to replace that part of my day” (R1 F30 NM)], while others reflected on the feeling of onset of the drugs [e.g. “I’d probably be more interested in something where I can feel a sort of like the onset” (R16 M30 NV)].

Daily dosing—medication for OUD synchronicity

Participants on medication for OUD indicated that it would be helpful if they could receive the daily dosage at the same time and location as their dosage for medication for OUD, which would streamline treatment access and adherence:

R: [Daily suboxone] seems to work now, and it wouldn’t have to change anything up. It would keep things kind of the same schedule. That could maybe you know, if I was able to go to you know, one trip or not having to see different place. (R2 M20 NM)

This suggests an opportunity to synchronize medication for MUD and OUD treatment for individuals seeking to reduce both opioid and methamphetamine use.

Monthly dosing—convenience

Others indicated that they would prefer a monthly injection to a daily dosing schedule, based mostly on convenience. Many noted that remembering to take medication on a regular basis can be challenging for people who use methamphetamine:

R: For meth [treatment], I don’t see a pill. I see people who do meth just not being able to take the pill because they forget about it or something. They lose them or something. (R11 M20 NV)

R: Pills, people forget. If there’s an injection you go like once a month or once every three months or something like that to the doctor’s, and it lasts and if you’re at a level that you know that works, I can see that being possible. (R19 F40 NV)

Individuals indicating preference for a monthly injection did not express a desire for routine that the participants preferring a daily dosage did. Those responding that they desired a daily schedule largely applied the logic of replacement therapy, with an emphasis on needing a replacement that provides similar functional benefits. Whereas those preferring monthly injections were more likely to reflect on the challenges of adhering to a daily regimen as opposed to reflecting on needing an alternative to provide similar functional benefit.

Skepticism—medication cannot fix environment

When asked about their interest in a potential medication, a few participants rejected the notion that a medication could, alone, address the root causes of methamphetamine use. One participant responded with heavy sarcasm that, even if it could help him end his methamphetamine use, he would struggle to navigate the same environment, assuming all other things stayed the same:

R: Okay. That’s great. I’m going to start taking a medication that makes you feel like that that I could get off drugs. Where am I going to go? How am I going to restart again? Okay. This is all going to still be on my mind. (R15 M35 NV)