3.1 Participants’ stimulant use profiles:
Participants were sampled from the RUTH study, which represented a cohort of people who had reported on average over 15 years of illicit stimulant use (i.e. cocaine and/or crystal methamphetamine) at baseline prior to initiating iOAT [5]. Table 1 displays the demographic and stimulant use profiles of participants. Following the sampling strategy, a diversity of stimulant use profiles are represented. The sample also had a broad rang of self-reported exposure to the medication (reported to range from approximately 1 week to approximately 3 years total), and included people currently (n=7) and formerly (n=13) receiving dextroamphetamine. Of those who had discontinued dextroamphetamine, some had an interest in receiving it again in the future, while others did not. Five of these 13 participants had transitioned to receiving another prescribed stimulant (methylphenidate (Ritalin)) which was offered for patients not responding to dextroamphetamine.
Table 1: Participants’ demographic and stimulant use profiles
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N=20
N (%)
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Gender
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Man
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17 (85.0)
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Woman
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3 (15.0)
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Average age (years)
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53.65 ±7.84
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Illicit stimulant use profiles at time of dextroamphetamine initiation
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Any Cocaine use
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12 (60.0)
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Crack cocaine smoked
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5 (41.6)
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Cocaine powder injected
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7 (58.3)
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Crystal methamphetamine use
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12 (60.0)
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Crystal methamphetamine smoked
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1 (8.3)
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Crystal methamphetamine injected
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11 (91.7)
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Footnote: Note, 4 participants reported injection of both cocaine and methamphetamine
3.2 Findings of thematic analysis: There were three central themes identified as related to participants’ experiences receiving dextroamphetamine which influenced their perceptions of this medication as an effective treatment for stimulant use disorder. These were: (1) achieving a substitution effect; (2) reaching an adequate dose; and (3) ease of medication access.
3.2.1 Achieving a substitution effect: Participants sought a range of effects from the use of illicit stimulants. Perceptions of dextroamphetamine as an effective treatment for stimulant use disorder were impacted by the extent to which it was seen to provide a substitution for the effect they received from the illicit stimulant they were using. For example, one participant who had previously attempted dextroamphetamine but was no longer receiving it said:
“If it [Dextroamphetamine] is going to be a maintenance drug it would have to have the ability to take the place of the drug you are trying to get people to stop using.”- Jason, 40 year old man
The most commonly sought effects from dextroamphetamine was a boost of energy, alertness, or focus. Among many participants for whom the intended effect was a boost of energy, dextroamphetamine was reported to offer this effect. For example, one participant who reported injecting methamphetamine daily to help with wakefulness described that he gained this effect from dextroamphetamine:
“I wanted to get off of jib [crystal methamphetamine], or at least slow down. I have sleep apnea really bad and I need to stay awake and alert, that’s why I was taking jib, just to stay awake. I used Dextroamphetamine instead. It did what I wanted it to do, it kept me awake when I wanted to be awake, for me it is like a win win situation.” – William, 62-year-old man
For some participants, the desired energy was sought to support them in completing tasks and gaining focus that they otherwise struggled to find in the absence of the medication. This was discussed in the context of attention deficit hyperactivity disorder (ADHD) by a few participants, who described feeling that dextroamphetamine helped to “slow things down” or to provide “focus” (Jennifer- 43-year-old woman). One participant who had been regularly using cocaine and methamphetamine for many years described:
“It helps me to keep my thoughts focused and not scrambled, I am able to retain information, clean the house, just doing chores, you are a little more focused and you feel like you know what has got to be done and you just do it. [Before] I would not have had any interest in doing that, the difference now is it [dextroamphetamine] gives me what I need to speed up, to wake up and get with the program. The dexy [dextroamphetamine] seems to help me pull it all together. It kind of picks you up to a normal pace I don’t feel like I am going to fall asleep I don’t feel like I am gonna be wide awake I just feel like I am ok…I am not like lost in the fog anymore, I pulled out of the fog. I am awake.”- Dean, 59-year-old man
For some participants, dextroamphetamine was sought to support them in managing cravings for illicit stimulants. This was particularly true for people who were looking to fully stop or quit their illicit stimulant use. For some participants, cravings were managed to the extent that they no longer had an interest in the feeling provided by street stimulant use. For example, one participant who had been smoking crack cocaine daily described that the “taste” or craving for use was stopped by dextroamphetamine:
“It [dextroamphetamine] curbed the thriving for it [crack cocaine], you know. I was using it just to cut down on craving. Doing crack [cocaine] while you are on it doesn’t feel right it just turns me right off it. Dextroamphetamine kills the taste for it [crack cocaine]...I just want to get off it [crack cocaine]. All my money went to it- everything that I made went into it, I worked for it, I gave everything to it, and now I just want off it.” – Elijah, 52-year-old man
For participants for whom the intended effect of their stimulants was to get a “rush” or feeling of “euphoria”, dextroamphetamine did not provide a substitution effect. This was often discussed by referencing the preference for a short acting stimulant, where dextroamphetamine, because of its long-acting nature, was not seen as a “viable substitute” (Jason- 40-year-old man). For example, one participant who injected cocaine daily reported that the effect he gained from dextroamphetamine was not comparable to that of cocaine:
“It [cocaine] is like almost a rush of energy running through my body right. It is very euphoric and very addictive. My biggest problem with getting amphetamines for replacement is that they have too much of an afterlife right. I like cocaine because it’s short lived. I am high as a kite and I am down and normal in an hour, you wouldn’t even know I did it an hour later, but speed [dextroamphetamine] and all the other substitutes have a long half-life and it takes a couple hours to hit you and then it lasts another half evening and then you still feel the effects the next day.” -Leonard, 51-year-old man
3.2.2. Reaching a preferred dose: The extent to which dextroamphetamine was seen as an effective treatment for stimulant use disorder was tied closely to patients’ dose preferences. The speed with which the dose was increased (titration) and the maximum dose received were both important contributors to dose preferences. For some participants, these two things were closely connected, where they did not reach a dose that was high enough from their perspective, because the starting dose was not enough to attract them to the medication or to lead them to believe that it could possibly have any effect for them. Upon reflection (particularly in focus groups where people heard from their peers) some participants reconsidered and reported wanting to try dextroamphetamine again at a higher dose or give it a chance for a longer period of time.
The dosing protocol at Crosstown Clinic involved prescribed daily doses up to 120mg, 60 mg dispensed twice daily. Many participants made comparisons between the potential effect of this dose as compared to the quantity of methamphetamine or cocaine they currently used. Some participants viewed the maximum dose of 120mg as inadequate. In this context, sometimes the desire for a higher dose was discussed, while for others the preference for an instant release formulation medication was discussed. For example, one participant who reached the 120mg daily dose reported that he still did not achieve the effect he was seeking, and did not see dextroamphetamine as a suitable substitute:
“I want like a powerful stimulant that I guess keeps me awake and energized and makes me do my weird repetitive behaviors. I couldn’t picture going and asking the doctor to give me from like 10 pills to 35 dextroamphetamine pills or something. That is what the dose would need to be to maybe be [what I need]. It would obviously come to a point where it would have an effect but I don’t want to be like having to take a ridiculous amount of pills. I wish Adderall had been covered so I could have been given a chance to try that just to see, I have a feeling that might have been a lot more effective” – Jason, 40-year-old man
It is important to note that communication with the prescriber when beginning the prescription was important to reaching an effective dose. This was challenging for patients who reported not regularly engaging in iOAT, or for people who were managing other concerns related to their health. For example, one participant who injected crystal methamphetamine multiple times daily described not having regular check-ins with his prescriber and stopping the medication prior to reaching an effective dose:
“I should have told them [prescriber] that it wasn’t enough but I went long periods without seeing them…I never actually approached them and said I want you to up the dose…I think it could be a positive thing If you get enough, for other people I have heard lots of good things. I would try it again because I would like to get off speed [crystal methamphetamine].” -Jeremy, 51-year-old man
Participants also discussed the speed of the titration protocol and suggested regular check-ins during the first few days on the medication to help ensure there would not be a preference to return to street stimulant use. Participants recommended starting at a higher dose (e.g. 30mg twice per day rather than 15 mg twice per day), one that was “enough to make a difference- to prevent them [the patient] from running out of the place and going to buy some dope” (Michael- 66-year-old man) and titrating up faster to ensure the patient did not become “disinterested”. One participant who was currently receiving dextroamphetamine reported that he only gained benefit from the medication when he reached the maximum dose of 60mg twice per day:
“For a while there I was thinking I might as well just quit it [Dextroamphetamine]. I started at 15mgs twice a day… that was too low of a dose, I didn’t know it was gonna really work you know like I knew I was cutting back a little bit but I couldn’t see it to a means to an end. I went and started off with 2, and then went 2 more. When I got on 3 two times a day that started to help quite a bit, I didn’t need the jib [crystal methamphetamine], and it didn’t interfere with my sleep. Now I get 4 twice a day and it is enough to keep me going and it is not interfering with my sleep at all so it is working for me, but I think people should start off on a better dose.”
-Aaron, 71-year-old man
3.2.3 Ease of medication access: Overall, experiences relating to the ease with which the medication could be accessed were described to influence perceptions of the medication. Participants had diverse goals and different preferences for the level of engagement they had with their OAT and stimulant treatment. Some participants were content with the integrated model of delivery, where the medication was offered within the iOAT clinic. Participants saw this as a convenient form of medication delivery and appreciated the medication reminders and dispensation from the on site pharmacy. One participant who had been visiting the clinic daily for many years outlined the ease of access from her prescriber, and the convenience of having access to dextroamphetamine at the same location and at the same time as her other medication:
“I liked the convenience of it. The fact that you could get it when you get your other meds. Like I didn’t have to go somewhere separate for it. It wasn’t very difficult for me to get it from my doctor.” – Elizabeth, 49-year-old woman
Other participants reported the reliability and consistency of access to the medication, for example having the option to take the medication on days when they wanted and to leave it when they did not. Participants reported comfort in knowing that taking a break from the medication for a period of time would not hurt the possibility of receiving it in the future. For example, one participant who had been smoking crack cocaine for many years reported changing events in his life, deciding to return to using crack cocaine stating that the cocaine was the “only thing in my life keeping me sane”. He reported that he would like to try dextroamphetamine again in the future:
“I stopped taking it a while ago, I was taking it but at this point in my life I am not trying to curb my crack intake...I probably will try it again… I have an open script with it so anytime I want to start it up again I just go and talk to the doctor and he will start writing it up again so that has been nice, so anytime I want it it’s there, and knowing that it’s there is a big plus.”
- Matthew, 55-year-old man
Many participants described wanting to have access to take home dose (i.e. carries) of dextroamphetamine. This was seen to impact on the potential effectiveness of the medication, given for many people the timing of their craving for illicit stimulants did not line up with the timing with which they were able to receive the medication at the clinic, for example one participant shared “my crack ridges [cravings] don’t follow any schedule” (Matthew, 55 year-old man). Furthermore, participants engaged in different activities outside of the clinic each day, and for many, further flexibility in the delivery of this medication would be required in order to allow dextroamphetamine to fit into those routines. For example, one participant outlined that he would only see benefit from the medication when he had control over when he took it, and taking it at the same time as his iOAT dose was not always preferred:
“If they give them [dextroamphetamine pills] to me [to take home] I would take them when I need them instead of taking them for the sake of taking them. They have certain times they hand them out and I don’t need them right then. Sometimes when I need them, I don’t have anything to get me to where I want to be and I have to wait until the next time, whereas if I was given them I could take them when I need them… Sometimes at night I could use more, not always, but if I am doing something, I might want to have some at night.
– Dean, 59-year-old man
Furthermore, one participant described that each day was a little different for him, where he might want to change the timing of dose administration depending on his work and sleep schedule. He also spoke that medication diversion was not something he would consider and should not serve as a barrier to carries:
“It [dextroamphetamine] works better if you can take it when you need it. Sometimes I am tired and can’t stay up it is nice to have it so I can keep it on me for when I need it. It keeps me awake for work right, and I work 3 days on and 3 off. And that’s what the carry does too, on my days off maybe I want to take it a little bit later if I want to have a nap and take it when I wake up. You know there is no reason why I could not take it for a month and quite easily dose myself. It’s not something I would sell; I work to make money and it’s just for my personal use. My body knows when I need it without having to walk down to the same place [iOAT clinic] every day just to get it.” – William, 62-year-old man