Author	Affiliation
Callan Elswick Fockele, MD, MS	University of Washington School of Medicine, Department of Emergency Medicine, Seattle, Washington
Sophie C. Morse, BSc, BA	University of Washington School of Medicine, Department of Emergency Medicine, Seattle, Washington
Jenna van Draanen, PhD, MPH	University of Washington School of Public Health, Department of Health Systems and Population Health, Seattle, Washington; University of Washington, Department of Child, Family, and Population Health Nursing, Seattle, Washington
Sarah Leyde, MD	Harborview Medical Center, University of Washington, Department of Medicine, Seattle, Washington
Caleb Banta-Green, MSW, MPH, PhD	School of Public Health, University of Washington, Department of Health Services and Population Health, Seattle, Washington; University of Washington School of Medicine, Addictions, Drug & Alcohol Institute, Department of Psychiatry and Behavioral Sciences, Seattle, Washington
Ly Ngoc Huynh, MSW	University of Washington School of Medicine, Department of Emergency Medicine, Seattle, Washington
Alina Zatzick,	University of Washington School of Medicine, Department of Emergency Medicine, Seattle, Washington
Lauren K. Whiteside, MD, MS	University of Washington School of Medicine, Department of Emergency Medicine, Seattle, Washington

Introduction
Methods
Results
Discussion
Limitations
Conclusion

INTRODUCTION

Methamphetamine use is on the rise nationwide¹ with an increasing number of emergency department (ED) visits,^2,3 behavioral health crises,^4-7 and deaths associated with use and overdose.⁸ Racial inequities related to methamphetamine use are also increasing, with the highest prevalence of methamphetamine use⁸ and the greatest increases in overdose deaths among American Indians/Alaska Natives. Non-injection methamphetamine use increased 10-fold among Blacks, a much steeper increase than that among White or Hispanic populations.⁹

Methamphetamine is a leading cause of substance-related ED visits.^10,11 The reasons for seeking ED care when using methamphetamine varies with patients requiring anything from medical evaluation for chest pain to sedation and psychiatric evaluation for agitation and psychosis.¹² In some areas, behavioral crises related to methamphetamine use account for half of psychiatric emergency services visits.¹³ Additionally, patients who inject drugs, such as methamphetamine, seek ED care for injection-related medical complications.² Emergency department visits related to methamphetamine are also likely to involve trauma and/or interactions with law enforcement officers.^14,15 Along with the increase in methamphetamine-related ED visits for medical and psychiatric reasons, emergency clinicians describe methamphetamine use as a significant problem with high resource utilization and risk of violence against staff.^16,17

There is limited literature examining the perspectives of people who use methamphetamine on their health, limiting opportunities to provide care based on patients’ experiences. Among people who use methamphetamine at syringe-access programs across the state of Washington, many were interested in reducing or stopping their use¹⁸ and wanted assistance addressing their medical and social needs through counseling, treatment, and care navigation.¹⁹ However, there are no known studies exploring the ED experience of people who use methamphetamine.

Given the increasing prevalence of methamphetamine use and the increasing number of ED visits related to methamphetamine use disorder, it is imperative that EDs consider the best way to serve this population. For patients with opioid use disorder (OUD), EDs have expanded lifesaving buprenorphine prescribing and take-home naloxone programs nationwide,^20,21 activities that undoubtedly have improved the care for patients with OUD.^22-24 In contrast, there is currently a paucity of pharmacotherapy, psychosocial interventions, and harm reduction strategies targeting patients with methamphetamine use disorder. In this study our primary objective was to identify the motivations of people who use methamphetamine and their experiences in the ED. Secondary objectives were to inform key stakeholders, address stigmatizing behavior in healthcare settings, and guide future ED-based approaches.

 

Population Health Research Capsule

What do we already know about this issue?

Methamphetamine use is rising with more emergency department visits, behavioral health crises, and deaths associated with use and overdose.

What was the research question?

What are the motivations of people who use methamphetamine and their experiences in the ED?

What was the major finding of the study?

Fifty percent of participants reported that their ‘main drug’ was methamphetamine while 15% preferred methamphetamine and heroin, suggesting that polysubstance use is common.

How does this improve population health?

Emergency physicians should recognize the complex motivations for methamphetamine use and provide tools to promote patient wellbeing through trauma-informed care.

 

METHODS

Study Design and Setting

From April–September 2020, we administered close-ended questionnaires and conducted semi-structured interviews with adults residing in the state of Washington who were at moderate to high risk for methamphetamine use disorder, had presented to an ED within the prior three months, and had access to a phone. The study was approved by the University of Washington Institutional Review Board, and a Certificate of Confidentiality was obtained from the National Institutes of Health.

Selection of Participants

Participants were recruited through convenience and snowball sampling. Flyers were sent to community substance use treatment clinics, peer support groups within Seattle, WA, supportive housing facilities, office-based opioid treatment programs, opioid treatment programs, and syringe-access program locations. Interested people called our study phone and were screened for eligibility by a trained research assistant (RA). Inclusion criteria included residence in the state of Washington, access to a phone, self-reported ED visit in the prior three months, methamphetamine use in the prior 30 days, and National Institute of Drug Abuse (NIDA)-modified Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) score consistent with moderate or high risk for methamphetamine use disorder.²⁵

Those eligible and interested in completing the study next provided verbal informed consent and completed a baseline survey by phone. The study RA directly entered the participant answers into a database using REDCap²⁶ electronic data capture tools hosted at the University of Washington. All participants who completed the survey received a $5 gift card. Participants were then invited to be interviewed. We obtained survey data from 25 participants and completed semi-structured interviews with 20 of these participants. The 20 individuals who completed the semi-structured interview provided verbal consent, completed audio recorded interviews over the phone, and received $25 gift cards. After completing an initial set of 10 interviews, we performed purposive sampling of participants who were eligible and completed the baseline survey based upon gender and race for the remaining interview participants to include more diverse perspectives.

Measurements

During the survey, participants were asked how often they had used methamphetamine in the prior 30 days before undergoing the NIDA-modified ASSIST²⁵ to determine risk for methamphetamine use disorder. Participants were next asked to identify their “main drug” to identify their drug of choice. Participants were also asked single-items questions on lifetime intentional fentanyl use and lifetime intentional GHB use. Validated single-item questions about tobacco, vaping, and alcohol were asked. We used the Patient Health Questionnaire-2²⁷ and the Generalized Anxiety Disorder-2²⁸ to screen for depression and generalized anxiety disorder in the prior two weeks, respectively. The human immunodeficiency virus (HIV) Risk Behavior Survey was used to determine behaviors related to injection, as well as current HIV and hepatitis C virus status. Demographic information, including age, gender, employment, and housing status, were collected. Qualitative semi-structured interviews focused on methamphetamine use, ranging from the causes behind their initial use to current use patterns, as well as on ED experiences, focusing on the patient’s last ED visit related to methamphetamine use, their experiences seeking and accessing care, and their thoughts regarding how the ED could meet their needs. The interview guide was refined iteratively, and the final guide is included as an appendix.

Analysis

Using descriptive statistics, we analyzed the survey results for participants who completed the survey and the semi-structured interview. The quantitative analysis was restricted to the 20 participants who completed both the survey and the interview. Semi-structured interviews using a standardized interview guide were recorded, transcribed, deidentified, and uploaded to the qualitative data management software Dedoose (SocioCultural Research Consultants, LLC, Manhattan Beach, CA). We used a modified grounded theory framework^29,30 to continuously collect and analyze the qualitative data. The grounded theory framework^29,30 allows the results to emerge from the data without a preconceived hypothesis. Therefore, coding of the manuscripts proceeded in an iterative fashion allowing data and codes from the initial manuscripts to inform the results codebook.

Specifically, we conducted three initial interviews with an interviewer (LH) who had experience conducting semi-structured interviews and working with the target population. After these initial interviews, three members of the research staff (LH, SM, AZ) each independently reviewed two transcripts and inductively developed and applied codes to the transcript.³¹ This process iteratively refined the codebook. These members and the principal investigator (LW) then met as a group until consensus was achieved on the codebook, with LW as the arbitrator. Finally, subsequent semi-structured interviews were conducted by the same trained interviewer (LH) until thematic saturation was reached.

RESULTS

Quantitative Results

Of the 25 participants who completed the survey, we interviewed 20 adults who met inclusion criteria (Tables 1 and 2). The mean age of our participants was 41.5 years (SD 8.7 years), and most participants were White cisgender men. All participants reported experiencing homelessness at some point in their lifetime while 40% were unstably housed at the time of the interview. Ninety percent were unemployed. Many participants reported current polysubstance use. Among this sample of 20 people who reported currently using methamphetamine, 10 (50%) reported that methamphetamine was their drug of choice, while 45% reported methamphetamine combined with something else to be their preferred drug. Sixty-five percent had injected methamphetamine in the prior month, and 55% reported that their main route of administration was smoking. Thirty percent had visited the ED because of methamphetamine use in the prior 30 days. Most respondents noted physical and/or psychiatric symptoms associated with methamphetamine overdose, or “overamping,” in the prior 12 months.

Qualitative Results

Our study’s major theoretical contribution is that participants described a shifting line that separates the positive attributes from the negative consequences of using methamphetamine. This was best summarized by one individual, who explained: “I kept drawing lines of delineation. . . .It was just going to be when I was hooking up, and then it was just going to be on weekends. Then, it was just going to be not on workdays. And then it was going to be I was never going to inject. That line just kept moving.” This line also represents interviewees’ complex, occasionally paradoxical, and often shifting experiences with methamphetamine, including enhancing function while also inducing crippling paranoia, fostering friendship while also leading to unequal relationships, and addressing untreated trauma while also exacerbating it. Several themes straddled this line: 1) hypervigilance and overamping; (2) socialization and isolation; (3) treatment and withdrawal; and (4) experiences in the ED.

Hypervigilance and Overamping

Many interviewees reported initially using methamphetamine to enhance their function, whether it was cleaning, working, or studying, and to provide protection in harsh conditions like homelessness. However, this hypervigilance often led to “overamping” when a participant might have felt that they were overdosing, “paranoid,” and “exhausted” (Table 3).

Socialization and Isolation

Participants described how methamphetamine originally improved their social interactions. They frequently started using with friends in social settings or to enhance sex. However, continued use regularly led to isolation and “stopping participation in life.” Individuals experiencing methamphetamine-induced paranoia felt uncomfortable around others, and repeated bingeing (ie, multiple days of consecutive use) often contributed to losing family, friends, jobs, property, and “personality.” Others recounted how individuals capitalized on their drug use, preyed on their vulnerabilities, and fostered unequal relationships (Table 4).

Treatment and Withdrawal

Many interviewees used methamphetamine to self-medicate, stabilizing their mental health, numbing their senses to escape difficult circumstances, and counteracting the negative effects of other drugs. However, the increasing need to use methamphetamine to combat withdrawal symptoms led participants to “hustle” and engage in increasingly risky behaviors, like sex work, to obtain the resources to purchase enough to avoid feeling sick (Table 5).

Experiences in the Emergency Department

Interviewees often experience stigmatizing healthcare interactions because of their methamphetamine use. Many described undertreatment of pain, difficulty obtaining intravenous access, unhelpful referrals, and traumatizing experiences, particularly while intoxicated with methamphetamine. Because of these overwhelmingly frustrating experiences, participants anticipated difficult interactions with healthcare clinicians, frequently leading to combativeness, avoidance of the ED, and downstream medical complications (Table 6). Nevertheless, methamphetamine use often drives patients to EDs, where they would like to receive resources, shelter, and treatment (Table 7).

DISCUSSION

Experiences with overamping, isolation, and withdrawal mirror the current literature describing the negative consequences of use,³² but participants also explored how methamphetamine can enhance function and strengthen relationships. This “moving” line between methamphetamine’s risks and benefits highlights the need for nuanced conversations about substance use in medical settings. People who use methamphetamine often want to reduce their use, but their motivation and goals are fluid.¹⁹ Emergency physicians should recognize the complexity of patients’ motivations and provide tools to promote wellbeing. They should aspire to provide trauma-informed care³³ to those who use drugs by better understanding each patient’s unique history and recognizing the health effects of stigma.³⁴

Participants frequently acknowledged the dangers of methamphetamine and wanted help but purposefully avoided medical care because of the perceived discrimination from healthcare staff. Many cited disrespectful interactions, undertreatment of pain, difficulty obtaining intravenous access, unhelpful referrals, and traumatic experiences in the ED related to their methamphetamine use. Interviewees hoped for, but rarely encountered, clinicians who acknowledged addiction as a chronic condition, addressed symptoms adequately, and provided positive connections to outpatient resources. This stigma experienced by people who use methamphetamine mirrors stigma experienced by people who use opioids.³⁵ Moreover, many methamphetamine-related ED visits for behavioral health concerns include chemical and/or physical restraints, which can feel dehumanizing to patients.

Emergency physicians can learn from community harm reductionists at syringe service programs and safe consumption sites about how to change this culture and create a protected space for people who use methamphetamine.³⁶ The distribution of safer use supplies, such as syringes and pipes, decreases risky behaviors and the spread of infectious diseases while promoting more collaborative medical interactions.^37-45 Because methamphetamine use is associated with high-risk sexual practices, clinicians can also consider sexually transmitted infection testing, treatment, and prevention services. Whether or not these services could be expanded to emergency care settings should be further explored.

Although not widespread, harm reduction principles have been successfully integrated as pilot programs into traditional clinical settings, which could be used as models in other environments. One hospital system created a multidisciplinary and interprofessional care conference to expand treatment options for patients with substance use disorders needing prolonged antibiotic treatment for conditions like endocarditis and osteomyelitis.⁴⁶ As part of their efforts to improve access to addiction care in emergency departments, CA Bridge, a program of the Public Health Institute in Oakland, California, has created adaptable materials on harm reduction kits, discharge instructions, strategies for hospital settings, and order sets based upon the experiences of selected clinical partners.^47-50

Lastly, as in other published work,⁵¹ participants expressed interest in accessing treatment and reducing their methamphetamine use. Although an effective pharmacotherapy for methamphetamine use has not yet been developed, there are several effective, yet underutilized, psychosocial treatments for methamphetamine use disorder. Contingency management⁵² reinforces positive behavioral change with rewards. Examples of incentivized behaviors include abstinence, engagement in therapy sessions,⁵³ and harm reduction.⁵⁴ Rewards typically include prize draws in cash or gift cards of escalating value. Although contingency management can be effective on its own, it can also be paired with the community reinforcement approach,⁵⁵ which uses social, recreational, familial, and vocational reinforcers to help patients engage in non-substance-use related activities and communities, so they can find meaning in a lifestyle that does not revolve around substance use.⁵⁶ A recent meta-analysis showed that contingency management coupled with the community reinforcement approach was the only evaluated treatment associated with decreased substance use at the longest follow-up time and increased engagement in treatment for individuals with stimulant use disorder.⁵⁷ Contingency management has been successfully implemented in homeless shelters,⁵⁸ community centers,⁵⁴ primary and specialized care clinics,^59,60 and sober living arrangements.⁶¹ Emergency physicians should consider creating referral pathways for patients who use methamphetamine in partnership with agencies providing these evidence-based interventions.

LIMITATIONS

The objective of this study was to identify the motivations of people who use methamphetamine and their experiences in the ED to guide future ED-based approaches. However, the results may only be applicable to the geographic location of the study population, which only included residents of the state of Washington. We used a convenience sampling frame to recruit participants, which may have introduced bias. Specifically, recruitment and interviews did not take place in person; therefore, this study may not have captured the voices of those with high social needs without access to a phone. Additionally, questionnaire data, including recent ED visits and substance use history, were self-reported and could not be confirmed with the patient’s electronic health record or through drug testing. Lastly, the study was conducted at the beginning of the coronavirus disease 2019 pandemic, while the “stay home, stay healthy” order was in place,⁶² which may have influenced participants’ perceptions of their medical care.

CONCLUSION

Methamphetamine use drives patients to EDs, where they often feel stigmatized and are provided little assistance. Emergency physicians can use trauma-informed care to change this culture and create a healing space for people who use methamphetamine. They can offer ultrasound-assisted peripheral line placement and treat symptoms of overdose, withdrawal, and pain. Using harm reduction principles, EDs can provide HIV and hepatitis C testing and distribute safer use supplies. Physicians can partner with a multidisciplinary team to improve access to social services and transitions of care to addiction treatment in the community. Future work should incorporate the perspectives of people who use drugs into ED-based programs and interventions.

Footnotes

Section Editor: Marc Matel, MD

Full text available through open access at http://escholarship.org/uc/uciem_westjem

Address for Correspondence: Callan Elswick Fockele, MD, MS, 325 9^th Ave, Box 359702, Seattle, WA 98109. Email: cfockele@uw.edu. 3 / 2023; 24:218 – 227

Submission history: Revision received August 14, 2022; Submitted December 12, 2022; Accepted December 16, 2022

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. This study was supported by K23DA039974 (PI Whiteside). There are no conflicts of interest to declare.

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