The participants

Sixteen potential participants were approached and invited to participate; 2 declined citing privacy concerns. Of the 14 participants who were recruited, 2 were female. The average age at the time of interview was 35 (range 29–39). All participants reported themselves to be opioid dependent (having initiated their injecting career during their teens) but also reported engaging in polydrug use. Ten participants were prescribed OST at the time of the interview.

Opioids reduce negative side effects of crystal methamphetamine

All participants reported that they were engaging in heavy periods of crystal methamphetamine use, with most reporting that this coincided with a rise in crystal methamphetamine availability in their local area. During periods of heavy use participants reported injecting crystal methamphetamine multiple times to obtain an intoxicated state, which lasted anywhere between 24 h and 2 weeks. Participants found it difficult to articulate why they were using such large quantities of crystal methamphetamine, often implying that they were unable to control their own usage. One participant stated that he was unaware of how heavy crystal methamphetamine use was affecting him for several months:

It went on for about six months, I was using every day. I didn’t know how fucked up I got until I got locked up and went to jail. I slept for ten days straight. I didn’t even get up to eat. (Participant 1, male, 33 years)

This participant explained that periods of heavy use typically stemmed from successive nights of partying, selling drugs and using. Other participants described similar experiences, explaining that they were using large quantities of crystal methamphetamine (a substance they considered ‘strong’) leading them to feel out of control both physically and mentally:

… it kept me up for such a long time. And this was just smoking it. I would be up for days and I would be using heroin to try and put me to sleep but nothing would work. I had no control. (Participant 2, male, 39 years)

Despite the lack of control participants felt when intoxicated on crystal methamphetamine, all participants reported continuing heavy use. Furthermore, participants also reported negative experiences during the ‘comedown’ phase of crystal methamphetamine intoxication. Sweats, shakes, dehydration, fainting and drug-induced psychotic episodes were reported as common symptoms during this phase, and it was evident that participants found these symptoms disturbing:

… when you are coming down you can feel it, you sweat it out of your skin and it stinks. It is revolting. (Participant 3, male, 36 years)

To ‘treat’ these effects, participants reported using a range of depressant substances. Whilst the most common substance was heroin, participants also reported using cannabis, benzodiazepines and mood stabilisers. These substances reportedly helped participants regain physical and mental control and often helped participants sleep after extended periods of crystal methamphetamine intoxication:

…when I’m coming down off it, I pretty much just go and get heroin, then I feel a bit better. But yeah, I can’t stand coming off it. It’s bad feelings. (Participant 4, male, 38 years)

I like the feeling of it [heroin], like just the way that it helps you sleep. And like, when I’m coming off the ice, just to get back down… coming off one hundred miles an hour (Participant 5, male, 35 years)

This pattern of co-use (using heroin during the ‘comedown’ phase of a crystal methamphetamine ‘high’) was commonly reported amongst participants, with many participants opting to do this if they were financially able; some participants reported that they often did not have enough money to purchase heroin to ‘comedown’.

Crystal methamphetamine prolongs heroin intoxication and forestalls opioid withdrawal

Participants reported that avoiding/alleviating the symptoms of opioid withdrawal was a primary concern for them. This included participants enrolled in OST programs, as many reported missing doses or that their prescribed treatment was not high enough to ‘hold them’. Participants reported that one injection of heroin would typically only satisfy their withdrawal symptoms temporarily and that after this time they were left ‘hanging out’ and in need of another injection:

Interviewer: How long would the heroin [injection of heroin] usually last for? Participant: I’d have to have a shot [injection], every 4 hours just to… yeah [stay intoxicated]. (Participant 5, male, 35 years)

During interviews, the topic of ‘cocktailing’ crystal methamphetamine and heroin (the use of crystal methamphetamine and heroin in the same injection) was frequently discussed by participants. A few participants reported that by combining heroin and crystal methamphetamine in the same injection, they could extend the effects of the heroin and therefore forestall the onset of opioid withdrawal symptoms. Participants loosely explained that this was due to the combination of depressant-stimulant effects, where they perceived that the stimulant drug prolonged the effect of the depressant:

For heroin on its own I could have a taste of heroin, then five minutes later I would want another one. Whereas if I had a cocktail, I’ll have one and I’ll be alright for about eight hours. It doesn’t come to mind and I don’t crave it, so I use less of it. (Participant 6, male, 31 years)

For these participants, the effect of combining the two substances meant that they were able to use less heroin to avoid opioid withdrawal; an outcome which was not only perceived to be physically beneficial but also cost-effective.

The combination of crystal methamphetamine and heroin ‘feels better’

Upon further discussion of crystal methamphetamine-heroin ‘cocktailing’, a few participants reported that the combination of crystal methamphetamine and heroin in the same injection ‘felt better’ than using either substance alone. Participants reported that the crystal methamphetamine could ‘boost’ the effect of the heroin, leading to a more desirable high. It was evident that these participants enjoyed this intoxication, and became accustomed to practising this regularly:

In this combination, it actually boosts the heroin and makes the heroin sensation stronger. It brings on the aroma of the heroin but you are also in this state where you want to be tinkering and doing things, or where you can drift off… (Participant 2, male, 39 years)

In further describing this practice, participants reported that it was important to use the correct quantities of crystal methamphetamine and heroin. Because the stimulant effects of crystal methamphetamine were strong, participants reported using only small quantities of crystal methamphetamine within the mix (the percentage reported between 5 and 20%) with the remainder of the mix being heroin:

Because ice is so strong, if you put one part heroin and one part ice, the ice will override the heroin so you basically waste your heroin. You won’t feel heroin. Even if you put half that, half ice to your heroin it is still too strong. I work at about a 5% to 10% ratio. (Participant 2, male, 39 years)

Although not all participants reported engaging in ‘cocktailing’ (some preferred the effects of each substance on its own), all participants were familiar with the practice, and many had tried it at least once.

Crystal methamphetamine replaces a heroin ‘high’ when on OST

Participants who were in an OST program at the time of the interview reported using crystal methamphetamine on days they were taking prescribed doses, and on days they were not. When regularly adhering to their OST regimen, many participants reported that the treatment satiated their physical opioid-dependency symptoms but not their psychological desire for intoxication. Thus, these participants reported seeking a ‘high’ from secondary substances, such as crystal methamphetamine, which would not be affected by their OST treatment. For a number of participants, using crystal methamphetamine on top of their OST treatment became a way of substituting a heroin ‘high’, and thus satisfying their psychological need for intoxication:

Yeah, it’s [crystal methamphetamine] a bit of a substitute, a big substitute actually. It just sort of satisfies me, much the same way that heroin did. (Participant 5, male, 35 years)

A common theme amongst participants was the perceived need to feel ‘high’, as participants reported they did not feel comfortable when they were not. Participants referred to the state of no intoxication as being ‘straight’ and explained that this state often made them feel anxious or depressed. Furthermore, participants on OST reported that they often felt ‘straight’ when regularly adhering to their OST treatment regimen and that even though they felt their physical opioid-dependency symptoms had been alleviated, the desire for intoxication remained. As one participant explained: