Motivation and context of concurrent stimulant and opioid use among persons who use drugs in the rural United States: a multi-site qualitative inquiry

BACKGROUND

In recent years, stimulant use has increased among persons who use opioids in the rural U.S., leading to high rates of overdose and death. We sought to understand motivations and contexts for stimulant use among persons who use opioids in a large, geographically diverse sample of persons who use drugs (PWUD) in the rural settings.

METHODS

We conducted semi-structured individual interviews with PWUD at 8 U.S. sites spanning 10 states and 65 counties. Content areas included general substance use, injection drug use, changes in drug use, and harm reduction practices. We used an iterative open-coding process to comprehensively itemize and categorize content shared by participants related to concurrent use.

RESULTS

We interviewed 349 PWUD (64% male, mean age 36). Of those discussing current use of stimulants in the context of opioid use (n = 137, 39%), the stimulant most used was methamphetamine (78%) followed by cocaine/crack (26%). Motivations for co-use included: 1) change in drug markets and cost considerations; 2) recreational goals, e.g., seeking stronger effects after heightened opioid tolerance; 3) practical goals, such as a desire to balance or alleviate the effects of the other drug, including the use of stimulants to avoid/reverse opioid overdose, and/or control symptoms of opioid withdrawal; and 4) functional goals, such as being simultaneously energized and pain-free in order to remain productive for employment.

CONCLUSION

In a rural U.S. cohort of PWUD, use of both stimulants and opioids was highly prevalent. Reasons for dual use found in the rural context compared to urban studies included changes in drug availability, functional/productivity goals, and the use of methamphetamine to offset opioid overdose. Education efforts and harm reduction services and treatment, such as access to naloxone, fentanyl test strips, and accessible drug treatment for combined opioid and stimulant use, are urgently needed in the rural U.S. to reduce overdose and other adverse outcomes.

Anxiety and threat-related attentional biases in adolescents with fragile X syndrome

BACKGROUND

Fragile X syndrome (FXS) is a single-gene disorder highly associated with anxiety; however, measuring anxiety symptoms in FXS and other neurogenetic syndromes is challenged by common limitations in language, self-awareness and cognitive skills required for many traditional assessment tasks. Prior studies have documented group-level differences in threat-related attentional biases, assessed via eye tracking, in FXS and non-FXS groups. The present study built on this work to test whether attentional biases correspond to clinical features of anxiety among adolescents and young adults with FXS.

METHODS

Participants included 21 male adolescents with FXS ages 15-20 years who completed an adapted eye-tracking task that measured attentional bias towards fearful faces of varied emotional intensity.

RESULTS

Among participants without anxiety disorders, attentional bias towards fear increased across age, similar to non-FXS paediatric anxiety samples. In contrast, participants with anxiety disorders exhibited greater stability in fear-related attentional biases across age. Across analyses, subtle fear stimuli were more sensitive to within-group anxiety variability than full-intensity stimuli.

CONCLUSIONS

Our results provide novel evidence that although threat-related attentional biases may correspond with anxiety outcomes in FXS, these associations are complex and vary across developmental and task factors. Future studies are needed to characterise these associations in more robust longitudinal samples, informing whether and how eye-tracking tasks might be optimised to reliably predict and track anxiety in FXS.