Our study showed that phases of ATS use and its users are diverse. Users have divergent motives for use, dynamic patterns of use with alternating phases of increase, continuation and decrease and different ways of and reasons for cessation. This heterogeneity is also a result of the diverse group of participants that we recruited by using a variety of recruitment strategies.
At initiation, use is often motivated by curiosity and pleasure-seeking, and sometimes to improve performance at work/studies or to cope with mental health problems. This is in line with previous studies (see for example Levy et al., 2005; Van Hout & Brennan, 2011). An increase in ATS use is often associated with an increasing orientation towards a drug-using environment (party lifestyle) or individual and social stressors such as a relationship breakup or mental issues (cf. Herman-Stahl et al., 2007; Levy et al., 2005). Occasional, controlled use was practiced by participants who prioritized everyday commitments and who used them on selected occasions. We also found mental health problems involved in most phases (cf. O’Donnell et al., 2019). Decrease or eventual cessation of ATS use was associated with experiencing serious health effects of use and increased stress from neglecting work, family and relationships. Many but not all of those with dependent or problematic ATS use had been in counselling and treatment. In contrast, ATS users who used primarily at parties or during nightlife often matured out of ATS use. Thus, for some, desistance or decrease phases were induced by turning points such as imprisonment or a new job, yet for others there never had been a conscious decision to quit. Availability seemed not an issue, regardless of the type of user, phase or country, while previous studies linked limited availability of particularly methamphetamine to decrease (Bourne et al., 2015).
ATS use, in its different phases, may bring a variety of harms for people who use these substances. An increasing body of studies has analyzed and proposed prevention, treatment and harm reduction interventions for people who use ATS. Studies usually investigate the effectiveness of interventions for a specific substance, or form of administration, and pay less attention to the phase of ATS use in which such interventions can be beneficial. By combining the findings of our study with this scientific literature, we propose evidence-based interventions which can be beneficial to reduce the harms of ATS use in the different ATS trajectories. Table 2 summarizes the recommended interventions, which are further described below.
Table 2
Recommended interventions for different phases of ATS use
ATS trajectory phase
|
Potential support and interventions
|
Initial phase
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• Evidence-based information on the effects and harms of ATS use
• Peer-led outreach and drug education
• Drug checking services
• Promote safer social settings
|
Continuation
|
• (Peer-led) information and counselling
• Drug checking services
• Nightlife safer use services
• Mental health support to help people cope with stressful life events
• Foster self-management and control of drug use
|
Increase
|
• Mental health support to prevent increased/uncontrolled use
• Skill-building, education and vocational training
• Foster self-management and control of drug use
• Drug checking services and nightlife safer use services
• Assistance with basic symptomatic detoxification and withdrawal
|
Decrease/ desistance
|
• Support controlled drug use or abstinence
• Ongoing therapeutic support for drug and alcohol dependence
• Skill building, education and vocational training
• Follow-up support after treatment
|
Dependent phase
|
• Harm reduction
• Services related to social integration, rehabilitation and care (e.g., housing services, work integration, activation programmes, debt control)
• Specialized, voluntary drug and alcohol dependence clinical treatment
• Follow up support after treatment
• Mental health support to help tackling (drug-related) problems
• Medication-assisted withdrawal programmes
• Substitution therapy if available and approved
|
Evidence-Based Information
Evidence-based information for ATS users about substances and their effects, and how to reduce potential harms of ATS use can be beneficial in several phases of ATS use. Important aspects to consider which information to provide are the motivations of specific groups for using the substance as well as users’ perceived risks associated with use (Rigg, 2017). Other important information includes the potential consequences of mixing ATS with other drugs, including alcohol (Kinner et al., 2012), the possibility of engaging in high-risk sexual behaviors (Rigg & Lawental, 2018), and educating users about potential sleeping problems as well as hyperthermia (Docherty & Green, 2010).
Peer-based interventions
Peers can play an important role in the development and implementation of interventions. Therefore, peers with experience of ATS use and preferably, part of the same sub-groups of ATS users for whom the intervention is planned should be meaningfully involved in the design and the provision of information and education programmes. Several ATTUNE participants linked peers to their initiation, continuation and decrease in ATS use. Peer-based programmes can be very effective, as information and knowledge is experience-based and can contribute to the credibility of the intervention (e.g. Korf et al., 1999). Peers are more effective in engaging with users (Jozaghi et al., 2016), and more easily trusted, as they share experiences and background. Peer outreach work is particularly effective for safer drug use education (Jozaghi, 2014) and peers can also offer counselling for supported withdrawal, including providing information around the withdrawal process, helping to identify protective and risky factors in previous withdrawals, and helping identify key social supports (Jenner & Lee, 2008).
Self-management of drug use
People who use drugs, including those using various types of ATS, are often able to control their drug use in varying levels of success (Zinberg, 1984). Self-management of drug use can lead to less problematic patterns of use (Chavarria et al., 2012) and increases the chances of becoming and staying abstinent of drugs (Ferrari et al., 2009). Stimulant drugs users often create (informal) rules to self-manage their use according to perceived risk and triggers, such as only using when feeling well, using only with friends or during weekends, and establishing a maximum amount or frequency of use (Rigoni et al., 2018). While self-management can be learned, and supported by peers, it must build upon users’ ability, empowering the skills and competencies they already use to control their use and reduce their risks (Zuffa & Ronconi, 2015).
Mental health support
Several people who use (certain) ATS do so to cope with difficulties and existing mental health problems (Fast et al., 2009). Frequent ATS use may also lead to mental harms such as depression, psychotic symptoms (hallucinations) and paranoid thoughts (Zweben et al., 2010). Moreover, chronic use is associated with high levels of psychiatric comorbidity (as depression, PTSD, ADHD, eating disorders and suicidal thoughts/attempts) (Grund et al., 2010). Mental health support, thus, can be used in initial phases to help people cope with stressful life events and prevent increased/uncontrolled use (Scott et al., 2013), or in dependent or continued trajectories, to help tackling the mental harms (partly) due to extended drug use. The connection between drug use and mental health disorder is complex and an integrated approach is urgently needed. However, integrated care models are limited or do not exist at all.
Drug checking services and nightlife services
The illegal status of ATS often leads to unknown dosages and contents, increasing the risk of overdose as well as of other harms. In this context, drug checking and nightlife services can help to detect adulterants in substances, which can decrease users’ intent to consume potentially dangerous substances, and help inform harm reduction efforts. These services can also be crucial for issuing preventative warnings (in case of dangerous adulterants), helping to avoid further harm. Nevertheless, drug checking alone might not be sufficient: especially less frequent users may require education about adulteration and drug-checking, and referral to support services and drug education are important facilitators of harm reduction intentions (Brunt & Niesink, 2011).
Safer Social settings
Interventions that are placed in and adapted to party settings can be very useful to engage ATS users in reducing harms, especially the ones in the initial phases of ATS consumption, but also those continuing or increasing use. Chill-out rooms at festivals or in clubs, for instance, can help MDMA users to increase their fluid intake and prevent hyperthermia, as well as warning users of the potential harm of overconsumption of fluids (Davies et al., 2018). Other practices include temperature control at the party venue, with adequate ventilation; provision of free cold water; staff training to understand and manage drug-related risks and emergencies; and adequate emergency provision (Transform, 2020).
Substitution therapy
Substitution therapy is an intervention used, in general, for a dependent pattern of drug use. While in the case of opiates drugs such as methadone and buprenorphine have been widely acknowledged as effective to substitute heroin, there is limited evidence of the benefit of pharmacotherapy for reducing ATS use. So far, studies have demonstrated only limited benefits for a few drugs, such as methylphenidate, bupropion, modafinil, and naltrexone (Lee et al., 2018).
Abstinence-based treatment and counselling
For those who are dependent on ATS and/or are willing to quit using, abstinence-based treatment and supportive counselling can be recommended. A few specific abstinence-based treatments have been developed for ATS, such as the Matrix model (Magidson et al., 2017). A specific structured brief counselling has been developed for regular methamphetamine users, and has proven to help increased abstinence, and manage the risks of tobacco smoking, polydrug use, risky injecting behavior, criminal activity, and psychiatric distress (Baker et al., 2005). Brief interventions have also shown to help reducing MDMA use and severity of MDMA-related problems (Norberg et al., 2014) and promoting readiness to change (Huang et al., 2011). In any treatment chosen, follow-up after treatment completion is crucial.
Limitations and future research
There were some methodological differences between the countries regarding sample size, incentives given, and recruitment procedures. These methodological differences could have affected the final creation of the sample and with that the comparability of the data between the countries. While we did not structurally compare countries, and while countries probably have yielded different user types due to different ATS prevalence, for example methamphetamine is more prevalent in Czechia than in the Netherlands, findings between the countries were largely in accordance. Neither did we perform analyses of longitudinal patterns of use, i.e., change between the different phases. For the analysis no (true) distinctions were made between the type of ATS. Despite being aware of the differences between the different ATS substances and user groups, this procedure was chosen for emphasizing the phases of use.
For future research it might be interesting to focus more on motives and processes of decreasing ATS use. Especially studies which consider barriers and supportive factors within the phase of reducing or desistance of ATS use would contribute to the current lack of knowledge. Furthermore, it would be of major interest to learn more about the effectiveness of drug and alcohol treatment for ATS users, as services usually address drugs and alcohol problems in general, but our study showed that among dependent ATS users these often go along. Finally, an effect evaluation of the proposed set of interventions would be very beneficial regarding harm reduction for the different phases of ATS use.