In the UK, around 1 million adults use amphetamine-type stimulants (ATS) each year (Home Office, 2019; Scottish Government, 2019), and the UN reports that globally, these are the second most popular group of drugs after cannabis (UNODC, 2019). This group of drugs includes amphetamine, methamphetamine, MDMA (ecstasy) and mephedrone, but also many less well characterised novel psychoactive substances (NPS) and cognitive enhancers.
When we think about the types of drugs that people develop problems with, or those that present the greatest burden of harm to society, attention is primarily paid to opioids and crack cocaine (Public Health England, 2018), but in some European countries it is ATS that cause most concern (EMCDDA, 2019). Here in the UK, around 300 people died after taking ATS in 2018, and Public Health England report that around 13,000 were receiving drug treatment for help with these substances in England. So this is clearly a group of drugs that is still associated with significant harm.
Most people who use ATS (or other types of drugs) don’t require formal intervention, and most don’t suffer major harm. However, although use of ATS is generally time limited, because these drugs do have the potential to cause problems, it’s important to understand how use develops, and to understand the triggers and turning points that can lead to more harmful patterns of use for some people. Furthermore, if we wish to prevent people from initiating use of ATS in the first place, particularly young people, then drug education activities would also benefit from this knowledge.
Surprisingly, whilst we know quite a lot about the strength of relationship between various risk and protective factors associated with substance use, including ATS, we know very little about how these actually relate to the lived experiences of people who use drugs (PWUD) (ACMD, 2018). This is important because effective prevention, harm reduction, treatment and recovery interventions rely on insights into the roles that drugs play in people’s lives, and professional engagement with client groups can be improved by a more nuanced understanding of these factors. This can also help to improve consideration of the feasibility, acceptability, and implementation of treatment interventions in practice guidelines.
Dr Amy O’Donnell from Newcastle University (UK) and her colleagues undertook a systematic narrative review and qualitative synthesis that aimed to identify individual (e.g. risk perception, personality), social (e.g. friends and family, education), and environmental (e.g. policy and law, nightlife participation) factors that shaped ATS use careers over four critical stages: initiation, continuation, increase/relapse, or decrease/abstinence (O’Donnell et al., 2019).
The review protocol was registered on the PROSPERO database prior to the work being undertaken, and the methodology included the use of important systematic review tools such as SPIDER to assist with development of the search strategy, and the CASP critical appraisal checklist to evaluate the quality of reviewed literature.
A comprehensive search for qualitative or mixed methods work published in English between 2000 and 2018 was undertaken across a number of literature databases and websites. Identified papers were independently screened by a single reviewer, but qualitative coding was performed by two separate researchers.
In contrast to many reviews of quantitative and intervention research, a standard data extraction tool wasn’t used. Instead, the researchers read each paper line by line as if they were analysing a primary qualitative dataset. This meant that they thematically coded key themes as they were identified in the text, and were able to re-read, reflect, and develop the data as they proceeded. Data was presented in the form of a narrative summary and tables with identified influencing factors, explanations, and illustrative quotes.
In total, 39 studies reported in 44 papers and concerning 1879 PWUD were included in the review. The majority of work was based on interviews with PWUD, although there were a small number of ethnographies, focus groups, and document analyses included. The research population was heterogenous, reflecting that ATS include many different types of drugs and are used by a diverse set of people. Study populations included students as well as more marginalised groups such as sex workers and people who were experiencing homelessness. As is often the case in substance use research, the majority of studies were from the USA (n=23), and only three were from the UK. Most (n=27) papers were assessed to be of moderate quality, ten as high quality, and two as low quality. The types of ATS considered included NPS, psychostimulant medications for ADHD, and more traditional drugs such as the amphetamines.
Review findings were organised by influencing factor, and stage of use. It is difficult to provide a concise summary of the findings of a qualitative review in a summary blog, as data is not provided in the form of p values or effect sizes. The authors provide a very readable overview and handy infographic, so readers are encouraged to read the full paper at the publisher’s site (link below) as it is free of charge (open access).
Briefly, most of the reviewed research investigated factors influencing individual-level factors associated with initiation of ATS, and relatively little assessed key transition points when people might increase or decrease their use, leading to changes in the risk of harm.
Unsurprisingly, curiosity was one of the most important individual-level reasons identified for initiation of ATS, but use was maintained through the pursuit of pleasure, whether hedonic or sexual, as people become familiar with drug effects, and are better able to select drugs on the basis of the anticipated benefits or experiences they might bring. However, as social pursuits and self-identity converge around ATS, this brings the risk that use will escalate alongside a narrowing of social repertoire. Functional drug use, whereby people use ATS to help them cope with, or perform better at work activities was another reason why people started to use. Mental health featured prominently across ATS use trajectories, and drugs were used to self-manage symptoms, or later in the drug using career to help deal with stress or avoid newly emerging symptoms. Adverse health and social experiences, or simply a determination to stop using ATS were the main determinants of reductions in use or stopping use altogether.
Moving onto social factors, peer and family influences, including parental substance use, were important determinants of initiation. Related to individual-level functional factors, some studies suggested that work and professional cultures encouraged continuation and escalation of ATS as people felt pressured to perform. A small, but important body of research examined reasons why people reduced use, and this included awareness of harms to others, a breakdown in family relationships, or even simply getting a job that required responsibilities that were not compatible with substance use, or occupied time that would have otherwise been spent obtaining, using, or recovering from ATS use.
As might be expected, availability and access to ATS, and opportunities to use influenced initiation. This also included legal status, especially in relation to NPS, which were often freely and legally available before control. Social and economic exclusion, an important determinant of substance related harms more generally, was also key, and studies explored how adversity created by a lack or loss of opportunity, good quality housing, or employment or welfare support could lead to escalation of ATS use. For some people, fear of prosecution or imprisonment was an effective deterrent, although it should be noted that this did not appear to be a protective factor against initiation of ATS.
The authors highlighted the complexity of the factors underpinning ATS use trajectories. For a review of this nature it is not possible to identify one or two key conclusions, but their work emphasised the importance of appreciating the heterogeneous nature of ATS use in practice responses. By considering ATS use from a life-course perspective, and acknowledging that multiple, overlapping factors, may hold different importance at different stages of a drug using careers for different groups of people, we can tailor and adapt our interventions and other responses appropriately.
Strengths and limitations
This was a high-quality review, published in a field-leading journal, by a respected group of researchers. The review was strengthened by the use of robust research tools, a clear and transparent methodology, and the inclusion of a diverse body of work. The authors included all of the most important studies, and by including mixed-method studies, picked up papers that might have otherwise got missed in a purely qualitative review.
Limitations of the review primarily relate to the quality and research questions of the included literature, which is a weakness common to all reviews. Few high-quality studies were available, and the authors noted important gaps around environmental determinants of ATS, or work that provided a long-term perspective on substance use disorders and recovery. There is a growing literature on so-called ‘recovery capital’, and other theoretically informed perspectives such as recovery identity (ACMD, 2012, 2013), and so it may have been advantageous to present parts of the analysis and results within these existing frameworks. One perhaps understandable weakness of the work was a restriction to English language publications. ATS use is prominent in several Asian, European, and Middle Eastern countries, and the inclusion of this work may have offered additional insights.
Implications for practice
Overall, there were few findings emerging from the review that would necessarily lead to major changes in practice. Important determinants of ATS use such as socio-economic conditions, housing, work cultures, and lack of opportunity are big policy challenges, and require political and societal responses, although improvements can always be made at local and organisational levels.
On an individual and service level, the authors highlight the rapid escalation of use from initiation to more problematic patterns that can sometimes occur with ATS. Other recommendations are in keeping with good practice for substance use more generally, such as integrated and wrap-around services, inclusive services for underserved groups such as women, and mothers, or the need to address co-occurring mental health.
But to highlight these is not a criticism of the work, as these are exactly the types of support that people who use ATS might need, and which, unfortunately, is not always provided. Unlike treatment for people who might be using opioids, there are no pharmacotherapies such as methadone or buprenorphine for people who use ATS (see NICE guidance on this topic). Clinical guidelines suggest the use of techniques such as contingency management and psychosocial interventions for psychostimulants and club-drug style ATS. These often encourage clients to examine motivations for substance use, and to reflect on external factors, social triggers, and environments that maintain use. Skilled practitioners therefore not only require technical, clinical, and inter-personal knowledge, but also cultural and ‘real-world’ knowledge about those factors that may have led their clients to present to services, and which can also be built upon to support recovery.
Conflicts of interest
Harry receives funding from public grant awarding bodies for alcohol and other drugs research. His University departmental colleagues assisted in the development of the ERANID funding programme which supported this research (the ATTUNE Project), and he was part of an expert group that helped to set research priorities. However, he was not part of the grant awarding process. He sits on the ATTUNE study Advisory Group but made no contribution the design, analysis, or publication of the work described in this blog. He has also co-authored publications with several members of the UK ATTUNE team on a separate research project.
O’Donnell A, Addison M, Spencer L, et al (2019). Which individual, social and environmental influences shape key phases in the amphetamine type stimulant use trajectory? A systematic narrative review and thematic synthesis of the qualitative literature. Addiction 2019 114, 24-47.
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O’Donnell, A., Addison, M., Spencer, L., Zurhold, H., Rosenkranz, M., McGovern, R., . . . Kaner, E. (2019). Which individual, social and environmental influences shape key phases in the amphetamine type stimulant use trajectory? A systematic narrative review and thematic synthesis of the qualitative literature. Addiction, 114(1), 24-47. doi:10.1111/add.14434
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