The Consequences of methamphetamine regular use in Tehran: qualitative content analysis CURRENT STATUS: UNDER REVIEW

Background: In recent years, methamphetamine regular use has increased noticeably in Iran, and this can have harmful consequences for the health of individuals and society. Therefore, the aim of this study is to investigate the consequences of methamphetamine regular use in Tehran . Methods: This qualitative content analysis study was carried out by using conventional approach. Date were collected through observation and in-depth interview with 20 regular users of methamphetamine adult in Tehran (15 males and 5 female). Participants were selected through snowball and purposeful sampling method which continued until data saturation. Guba and Lincoln criteria were used to assess the strength of the research. Results: The extraction of the codes resulted in three main categories, including: 1. The short-term consequences, consisting of the sub-categories of individual and social consequences 2. The long-term consequences, consisting of the sub-categories of psychological and physical consequences, high risk behaviors, severely decayed memory and changes in the eating pattern. 3. hallucinations and delusions including the sub-categories of visual and auditory hallucinations, delusion of suspicion and delusion of having supernatural power. Conclusion: Methamphetamine regular use has serious adverse on overall health of individuals. Therefore, implementing educational programs in order to raise awareness and changing attitudes about the short and long term consequences of using methamphetamine in high risk group is highly recommended.


Background
Drug use is one of the most controversial issues in the field of social sciences [1,2], and dependence on it is recognized as a illness, as well as a sociopolitical and health problem worldwide [3]. Recently in Iran, consumption pattern of drugs has changed so that young generation who are willing to consume drugs are seeking new ones such as methamphetamine, crack and heroin [4,5].
Methamphetamine is one of the stimulant drugs [6], which has become popular in Iran with the name of crystal and is one of the most misused substances and its prevalence in Iran is 5.2% of consumers [7]. Insurance companies are reluctant to pay the costs when they detect a psychiatric problem due to drug usage. So, underreporting of drug consumption is a real problem [8][9][10]. The growth of methamphetamine consumption in the world [11] and Iran has become as an important problem for the health sector [12][13][14] at the individual and social levels [15,16].
Easiness of producing with uncommon compounds and different degree of purity, low cost and high income, easy availability, simple and little needed equipment, possibility of mass production, and difficulty in identifying laboratories make its trade very lucrative [17]. Although it can cause a lot of dangers, such as explosion, burns, lung burns and even cancer, for manufacturers and those who are near the places of production and exposed to waste [18][19][20].
The regular use of methamphetamine can have lifelong dangerous effects [21]. The results of Ahmad Hatim's 2011 research on methamphetamine dependence in Malaysia showed that the prevalence of psychiatric co-morbidity among these people was 54.4% and the prevalence of suicide was 12.1%. 47.9% of these people had high levels of methamphetamine-induced psychosis [15].
In 2012, Petit et al, found a significant association between methamphetamine addiction and personality disorders, cardiovascular, pulmonary, infectious and dental [11]. Sommers et al. in a study entitled Methamphetamine use among young adults: health and social consequences showed that the methamphetamine regular use was associated with consequences such as weight loss, seizures, and epilepsy. In addition, many methamphetamine abusers experienced severe psychological symptoms or diseases such as depression, hallucinations, paranoia, and violence [22].
Also In a systematic review of Marshall and Warb, there was a strong association between methamphetamine use and increased depression, psychosis and suicide mortality risk, but no association was found between methamphetamine use and infectious and dental diseases [23,24].
The abuse of methamphetamine creates a sense of euphoria and lightness in a person and is highly addictive. Methamphetamine rapidly enters the brain after taking and causes sudden secretion of neurotransmitters including norepinephrine, dopamine and serotonin. The most important consequences of the use of this substance include obsessive-compulsive disorder [25], fetishism [26], depression [27], antisocial behavior [28,29], violent behavior [30], movement disorders like Parkinson's disease [31], low mental health [32], insomnia [33], and risky sexual behavior [34].
Although many studies have been done on the side effects of methamphetamine throughout the world, most of them have been carried out quantitatively and experimentally. Crystal meth is produced in more different conditions in Iran [35]. Therefore, it has effects different from those of drugs produced in other countries. Also, since qualitative studies provide better understanding of phenomena and can explain human beings' life experiences, interpretations and perceptions in the cultural and social context that they occurred [36,37], there is a need for qualitative research in this field. Therefore, this study was conducted with a qualitative content analysis approach and with the aim of exploring the consequences of methamphetamine regular use in Tehran.

Design and sample
This research was conducted using qualitative approach and conventional qualitative content analysis. Qualitative content analysis is one of the qualitative research approaches for analyzing text data and is, in fact, a systematic classification and coding technique aimed at better understanding of the phenomenon under study [38].
The study population consisted of methamphetamine regular users in Tehran who had a history of at least three months persistent methamphetamine use and had not previously experienced use another drug. In-depth interview and observation were used to collect data. In fact, the first author of the paper only observed and noted the behaviors and physical symptoms of the methamphetamine regular user as a roommate without any intervention. Interviews were conducted by the first and eighth authors. Considering that one of the authors) first author (of this article experienced living with a methamphetamine regular user as a roommate for 5 months, the observations of the author were coded and analyzed to record the behavior of that person. The criteria to enter the study included methamphetamine regular use at the time of study, experience of at least three months methamphetamine regular use, no history of psychiatric disorder before methamphetamine regular use, not being addicted to other drugs at the time of the study and before it, and the willingness to participate in research. Regarding the subject of the research and the difficulty of samples identification, snowball and purposeful sampling was used.

Data collection and analysis
Accordingly interviews were conducted with methamphetamine regular users in Tehran until data saturation was reached. Data saturation occurred with interviews with 20 people including 15 men and 5 women. When the code obtained from the interviews is repeated and the researcher ensures that no new codes are formed by continuing the interview, the theoretical saturation will result and the researcher can interrupt the interview process because new information will not be obtained by continuing the interview [39].The duration of the interview was adjusted according to the willingness of the participant to answer the questions, which took an average of 40 minutes.
At the beginning of each interview, demographic questions were asked and then the interview continued with questions like How did you feel about the first time you methamphetamine use? What changes have occurred in your body, personality and personal and social behaviors due to short-term methamphetamine regular use (during the first six months)? What interesting things did you experience that you felt didn't happen to others during methamphetamine regular use? Explain the hallucinations you experienced after methamphetamine regular use. During the interviews full attention was paid to the appearance and body language of the participants for more comprehensive information. After each interview, the data was coded and analyzed.
After encoding and summarizing the data based on similarities and differences, the classification of codes was performed and the classes were compared together and ultimately, themes were extracted by the analysis and interpretation of these data. Graneheim and Lundman method was used to analyze the data [38]. In the first step, the whole content of the interview was transcribed word by word and read several times until a general concept of the text was obtained. Then the text was divided into independent concepts and marked with specific codes. In the next step, the codes were divided into subcategories and classified according to similarities and differences. Finally, the hidden content was found and reported. an example of analysis and coding is given in Table 1 (Table 1). Individual consequences enhancing sexual ability "The first month I was using c sexual power was very good, with myself." Social consequences Getting more social "I was always an aloof person always kept on at me about b but since I used crystal, I was anymore, I got so socialized, a family is pleased with me." Guba and Lincoln criteria were used to assess the accuracy and rigor of the present study [40]. As to credibility of the data, the author had a prolonged engagement with the participants to win their trust and have a better perception of their experiences. In addition, the coding and analyses results were forwarded to some of the participants to check if the results reflect their opinions and viewpoints (member check). To consider the transferability of data, the obtained information was examined and approved by three specialists who are experts in the field of qualitative research and methamphetamine studies. In fact, the process of coding and analyzing the data was sent to them and their comments were used to name the categories and sub-categories. Also a comprehensive description of the subject was provided and direct quotes from participants were used.

Ethics
In this study, ethical considerations were made in accordance with the Helsinki Declaration. This study was approved by the Ethics Committee of Iran University of Medical Sciences. All subjects were informed about the study and all provided informed consent. There was emphasis on maintaining privacy and respecting the honesty in keeping and delivering the information accurately without mentioning the names of the people. Subsequently, participants were given the right to leave the interview at any time, if they wished to leave the interview process, and they were promised to have the study results if they want.

Sample characteristics
The results showed that the average age of the samples was 27±7.36 years and the average duration of their drug use was 25± 25.41 months. Also, the majority of the sample were single, male and had bachelor's degree (Table 2).

Visual Hallucinations
Seeing strange things, seeing things other than their face in the mirror, the illusion of believing in things that are not real, the illusion of living with imaginary people, having horns on the head in the mirror, seeing someone sitting next to bed at night, seeing a little girl with long hair, illusion of seeing the elephant while driving, seeing trees as police officers, illusion of seeing the sea and the ship, illusions of hitting people by car (while they hit a cat), seeing small ants on the arm, claiming to see things that others cannot see, and the illusion of attending a big concert Auditory Hallucinations To hear the result of football game before it starts, to hear a voice encouraging the person to commit suicide, to hear the sound of walking feet in the sleep, to hear strange noises delusion of suspicion Conspiracy of colleagues to kill them, suspicion about spouse's betrayal, suspicion about neighbors for the desire to kill them, the illusion of being chased by anonymous people, the illusion of an individual coming to the room and moving the thing, the illusion of being harmed by others and the illusion of cameras being in the houses they rented. delusion of having supernatural power Believing in having the perfect sixth sense and the illusion of predicting everything (like results of soccer games) 1.
Short-term consequences: methamphetamine regular use initially has associated with positive outcomes, such as increased concentration and sexual ability, but these positive outcomes are not sustainable, and after some time these positive effects are replaced by negative outcomes, such as hallucinations and so on.
consequences that appear to be beneficial which make it more satisfactory to the person, but they are not sustainable.

1-1 Individual consequences: methamphetamine regular use initially causes physical and
psychological changes in an individual that can affect his or her behavior, and in some cases, these behaviors are appealing to a person.
Participant No. 7 said: "I got much more focused at the beginning of using crystal. I studied less, but I learned more and my grades were much better, I was very pleased with myself." Participant No. 1 said: "The first month I was using crystal my sexual power was very good, I was pleased with myself." Participant No. 11 also said: "when I started to use crystal, I got stronger and I lifted weights more than ever."

3-Common hallucinations and delusions Caused by consumption of methamphetamine:
One of the common consequences of methamphetamine consumption is the creation of hallucinations and delusions in people, which sometimes causes violence against themselves and others, and may even result in murder and suicide.

3-1 Visual hallucination: Methamphetamine consumption causes visual hallucinations in regular
users, such as claiming to see things that others cannot see.

3-3 delusion of suspicion:
Another problem that appears with the regular use of methamphetamine is the delusion of suspicion. It makes a person pessimistic about others and may lead to violence against them.

Discussion
This study aimed to exploring the consequences of methamphetamine regular use in Tehran. The results showed that methamphetamine consumption in the short period of time is accompanied by individual consequences such as being happier, increased confidence, increased concentration and improved sexual power and social consequences such as getting more sociable, etc., which can lead to more desire to continue consumption. This is in line with Kennedy (2015) [41], Bustani and Karamizadeh [42], Mohib Ali and colleagues [43], Sia Johnny et al [44]. . But over time, As showed at the result section this study, positive outcomes are gradually replaced by negative outcomes.
In Baangy et al, insomnia [32] and in Shakiba et al, increase of excitement and concentration [13] has been mentioned as short-term consequences of methamphetamine consumption.
Positive short-term consequences of methamphetamine may cause the family to be more pleased with the individual, and this encourages the person to continue. Since the families are more satisfied with the change in the person's behavior, they have less doubt that perhaps this change in behavior is due to methamphetamine consumption. But the regular use of methamphetamine in the long run is accompanied by extremely dangerous consequences for the individual and even the society, which can disrupt the life of the individual and society.
According to the findings of this study, the physical and psychological consequences, high risk behaviors , decayed memory and changes in the pattern of eating were among the sub-categories related to the long-term consequences of methamphetamine consumption. The results showed that long-term consumption of the methamphetamine would affect human body and could have harmful effects on it, endangering the health of the individual and even leading to their death. Previous studies reported the association between methamphetamine regular use and human physical health; for example, the relationship between the methamphetamine abuse and oral dryness(dry mouth), cardiovascular diseases [45], infectious diseases such as endocarditis [46] and teeth decay [47,48] has been proven in previous studies in this area.
Psychological consequences such as depression, having irrational beliefs about associates, thinking about suicide, insouciance about everything and obsessive-compulsive disorder are other long-term effects of methamphetamine consumption in this study. The results of previous studies showed that the abuse of methamphetamine is associated with the sustainable psychological changes in regular users, such as depression, isolation, personal conflicts [49], irrational thoughts [50], and obsessive compulsive disorder [28].
Another sub-category related to long-term consequences was high risk behaviors. Long-term consumption of the methamphetamine can change the person's behavior and increase the high-risk behaviors [51]. Changes in behavior and an increase in risky behaviors are the symptoms of longterm regular use of methamphetamine. Violence, aggressiveness, and hostile attitudes are also common in methamphetamine users. [52,53]. Also, regular using methamphetamine can increase the sexual need of an individual abnormally, and because of the other effects of this substance, it causes incontinence in a person, so that he no longer uses preventive measures and devices. And the person is forced to indulge in sexual activity with multiple people that can endanger the health of the individual and lead to AIDS, hepatitis and other sexually transmitted diseases [54][55][56][57][58] .
Another symptom of long-term regular use of the methamphetamine is memory disorder. Maxwell (2005) and Lundqvist (2005) found a significant relationship between the methamphetamine abuse and the decreased cognitive and psychosocial functioning in the individual [58,59] and caused problems such as memory decrease, confusion, and forgetfulness [60,61] Continued use can also result in memory loss, and people with it resemble those who have Alzheimer's disease [62].
Changes in the pattern of eating are another sub-category of long-term consequences which was a new findings that is not mentioned in other studies. Changes in eating pattern and excessive loss of appetite have to do with using methamphetamine so that the regular users lose weight and suffer malnutrition after a while. [63]. However, this consequence of methamphetamine consumption may be attractive for some. Maybe one of the main reasons of tendency to methamphetamine, especially for women, is their decision for weight loss. As shown in previous studies, the women who consume methamphetamine weight significantly less than the women who do not use it [64].
Another consequence of the regular use of methamphetamine is the hallucination and delusion in the user person which is not mentioned by previous studies . These hallucinations and delusions sometimes lead to social harm and murder, which unfortunately we see a title related to this issue (e.g. Crystal user Killed his Family) in the newspapers every day, and it increases day by day due to increasing the number of methamphetamine consumers. The common visual hallucinations that these people have include seeing things without real existence and no one else can see these things except them. In some cases, users have the hallucination of seeing insects on their skin, which results in scratching and wounding their skin, which is why many people who are use this drug usually have a lot of wounds [23,65]. In the studies of Baggott et al and Akiyama, visual hallucinations caused by methamphetamine use were also reported [66,67].
Auditory hallucinations also are observed in them, some of which sometimes stimulate the regular users to hurt themselves and others. Auditory hallucinations were also reported in methamphetamine-dependent in the study of Mahoney et al [68].
Another form of hallucinations and delusions that these people have is the delusion of having supernatural power, so that they think they have extra-human power and can fight the whole world; in fact, it creates a kind of false self-confidence in them. The majority of methamphetamine regular users believed they have superhuman strength to do extraordinary things, such as predicting the future, and because these people saw themselves as safe in danger, they took dangerous actions and endangered their health.
But perhaps the worst kind of delusions that these people have is the delusion of others' conspiracy against them [25]. In fact, many methamphetamine regular users experience this delusion that others are thinking about harming him or that their wife or husband plans to betray them. This type ofdelusion makes these people commit dangerous unpredictable behaviors. One of the new results in this study, not mentioned in previous studies, may be due to differences in the composition of methamphetamine made in Iran of different compounds and having different effects. Sometimes severity of these behaviors can be highly bothering for the society. The study of Mansourian and his colleagues also showed that methamphetamine users have suspicion about associates [65].

Strengths and Limitations
The present study is the first Iranian research that addresses the consequences of methamphetamine regular use in Tehran, the capital city of Iran, through a qualitative approach since first-hand information can be attained by doing so. Moreover, given that the first author of the present study himself had the experience of living with a methamphetamine regular user previously, the real behaviors of methamphetamine regular users could be identified and recorded easily to some extent.
Another strength of the study was the selection of subjects with no previous use any other drugs except methamphetamine, which per se could be helpful in discovering the specific consequences of methamphetamine regular use. However, there were some limitations, too. One of the main limitations was the difficulty of access to methamphetamine regular users, which was resolved through choosing an appropriate sampling method and drawing the trust of the samples to introduce their peer users friends. Another problem was determining the time and place of the interview, which was repeatedly changed by participants, which was then solved by the researchers through repeated visits to the place of the interview.

Conclusion
The harmful consequences of methamphetamine consumption can endanger the health of the individual, family and society. Therefore, raising the knowledge about the short-and long-term effects of methamphetamine regular use and its symptoms as well as providing appropriate programs to change attitudes toward the consequences of methamphetamine regular use can be an effective step in preventing the use of this drug. In addition, appropriate counseling to methamphetamine regular users and assisting their rehabilitation to return to a healthy life are recommended to control the adverse effects caused by the use of this drug.
Abbreviations MH: Methamphetamine use; QCA: Qualitative Content Analysis Declarations Ethics The study procedures were carried out in accordance with the Declaration of Helsinki. This study was approved by the Ethics Committee of Iran University of Medical Sciences. All subjects were informed about the study and all provided informed consent. There was emphasis on maintaining privacy and respecting the honesty in keeping and delivering the information accurately without mentioning the names of the people. Subsequently, participants were given the right to leave the interview at any time, if they wished to leave the interview process, and they were promised to have the study results if they want.

Consent for publication
Not applicable.