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Official websites use. Share sensitive information only on official, secure websites. Methamphetamine use is increasing in the United States, potentially including the simultaneous injection of methamphetamine with heroin goofball. We compared demographic, behavioral, contextual, and health factors among people who inject drugs PWID in the Seattle area and who reported that their main drug was goofball, heroin, or methamphetamine. Among PWID participants, PWID whose main drug was goofball reported considerable health risks and morbidity. Witnessing an opioid overdose was most commonly reported by participants whose main drug was goofball. This group also reported naloxone possession and use in an overdose situation more than other participants. The majority of participants were interested in reducing or stopping their opioid and stimulant use. Among PWID, using goofball as a main drug doubled over two years and was characterized by contextual and individual factors that increase risk of morbidity and mortality. This is the first study to characterize goofball use as a main drug. Clinical and public health efforts to diminish morbidity associated with opioid use need to integrate interventions that address co-use of methamphetamine. Methamphetamine use is increasing in the wake of the opioid crisis in the United States U. Increases in the use of this highly addictive stimulant have been documented in the health literature 1 , 2 as well as in the national media. Data from San Diego, California, and Tijuana, Baja California, Mexico have also demonstrated high levels of co-injection of methamphetamine and heroin. Although existing literature provides some insight into the characteristics and circumstances of people who inject goofball, the available data remain very limited. We previously published an analysis of data from syringe services program SSP clients in the Seattle area between and , and found that people who used goofball were significantly more likely than other PWID to be young, homeless, inject daily, and self-report an opioid overdose. In addition, it is important to focus on people whose primary drug is goofball to determine how the needs of this potentially high acuity group may differ from people predominantly using other drugs. The aim of this analysis was to assess how persons who consider goofball to be their main drug differ from persons whose main drug is heroin or methamphetamine alone in their injection risk behaviors, health outcomes, interest and experience with drug treatment, and in the contextual factors affecting their lives. Given the higher risk environments observed among people who use methamphetamine and heroin together, we hypothesized that people whose main drug was goofball would report higher levels of injection risk behaviors and adverse health outcomes e. Most clients are PWID seeking harm reduction supplies, but clients also include people who were obtaining supplies for others or engaged in on-site substance use treatment. Methods and results from the and earlier surveys have been previously published. Over two-week periods each summer, trained SSP employees and volunteers attempted to recruit all clients for a voluntary survey. Because there was no way to indicate which clients had already participated or declined to participate, clients were offered survey participation at each subsequent visit and asked if they had already completed the survey. Staff ensured that all clients, including those who previously participated and those who were not interested, received the services they were seeking. Participants gave verbal consent and could decline to answer any question. Interviewers read survey questions to participants and recorded responses directly into a REDCap database or first on a paper survey. SSP staff approached SSP clients in and clients in to complete the surveys; and , respectively, agreed to participate Because clients could have been asked to participate multiple times, this is likely an underestimate of the actual cooperation rate. Frequency of use for each drug was measured by the number of days used in the last 7 days and available in only. We included participants who indicated that their main drug was goofball, heroin by itself, or methamphetamine by itself in analyses comparing characteristics of people across these three groups. Men who have sex with men MSM included both cisgender and transgender men who reported having sex with men in the last 12 months. We assessed race and ethnicity by calculating the proportion of participants that selected each identity. We used data on the number of injection days in the last week to calculate if a participant injected daily. We also calculated the average number of drug injections per day. We created dichotomous variables for any syringe or other injection equipment sharing in the last 3 months based on the number of people with whom they reported each behavior. We estimated the proportion of participants who reported ever injecting into their femoral vein or jugular vein in the last 3 months. We estimated the proportion of participants that were currently getting treatment for their drug use, and if so, what type of treatment. We measured interest in reducing or stopping use of opioids or stimulants among people who reported using each type of drug. We calculated the proportion of participants who reported a series of health conditions in the last year: an abscess or skin infection asked as separate questions in ; an infected blood clot or blood infection; endocarditis; a sexually transmitted infection STI , excluding HIV or hepatitis C virus, HIV, or pregnancy women only. We constructed dichotomous variables to calculate the prevalence of an opioid or stimulant overdose in the last year and if a participant had observed someone else overdose on opioids or stimulants using data collected on the number of times a participant had experienced each outcome. The definitions for each type of overdose are provided in Table 3. We also estimated the proportion of participants who possessed naloxone in the last three months, and if so, if it had been used in an overdose situation. Abbreviations: mos. In this sample restricted to those who inject, we calculated the frequency of use of individual drugs between participants who reported any goofball use and those who reported no goofball use. We compared medians using the Kruskal-Wallis rank test. The majority Among participants who reported any goofball use, The proportion of PWID participants reporting that goofball was their main drug nearly doubled At the same time, there was no significant change between and in the proportion reporting any goofball use The proportionate increase in goofball as a main drug was similar across each of these drug use groups. Participants who reported any goofball use in the last 3 months reported using goofball a median of 5 days a week, while those who reported that goofball was their main drug used it a median of 7 days a week. Nearly all participants who used goofball in the last 3 months reported injecting goofball Higher proportions of participants who used any goofball use in the last 3 months reported using many other drugs than those who did not use goofball. As shown in Figure 1 , among participants who used goofball in the last 3 months, nearly all Higher proportions of participants who used goofball in the last 3 months also used powder cocaine, speedball, fentanyl, and benzodiazepines. Ninety percent of participants had health insurance, most of which was public insurance. Includes Medicaid, Medicare, U. The group whose main drug was goofball had the highest proportion of respondents who were homeless or unstably housed and incarcerated in the last year. On each of these demographic measures, participants whose main drug was goofball were more similar to those whose main drug was heroin than those whose main drug was methamphetamine. Men in the methamphetamine group were characterized by a higher proportion of MSM compared to the goofball and heroin groups. Participants whose main drug was goofball reported using goofball, heroin by itself, and methamphetamine by itself all for a median of 7 days per week Table 2. The median number of days of weekly goofball use were lower among participants who reported either heroin 3 days or methamphetamine 1 day as their main drug. Abbreviations: IQR, interquartile range 25 th th ; No. Participants could select more than one type of treatment. Participants whose main drug was goofball had the highest frequency of reporting many injection risk behaviors than participants whose main drug was either heroin or methamphetamine. These behaviors included injecting every day, a higher number of injections per day, sharing a syringe, sharing other injection equipment, injecting in public, and injecting into their femoral or jugular vein. One-quarter of participants whose main drug was goofball were currently in any treatment for drug use, which was similar to other participants. Methadone was the most common treatment among the heroin group, buprenorphine was most common in the methamphetamine group, and methadone and buprenorphine were evenly reported in the goofball group. Most opioid and stimulant users who were not in treatment were interested in reducing or stopping their use of each drug. Interest in reducing both opioid and stimulant use was highest among participants whose main drug was heroin. Participants whose main drug was goofball had the highest prevalence of abscesses, infected blood clots or blood infection, and endocarditis, while participants whose main drug was methamphetamine had the lowest prevalence Table 3. By contrast, participants whose main drug was methamphetamine had the highest frequency of reporting a bacterial sexually transmitted infection STI or HIV. Participants whose main drug was goofball reported a similar frequency of experiencing an opioid overdose as those whose main drug was heroin, but there was a significant difference between groups regarding witnessing an opioid overdose with the goofball group reporting the highest level. Trends in naloxone possession followed a similar pattern, with more participants whose main drug was goofball reporting naloxone possession in the last 3 months and use in an overdose situation than other PWID participants. One-third of participants whose main drug was goofball reported experiencing a stimulant overdose or overamp in the last 12 months compared with Findings from these recent surveys of SSP clients in Seattle showed that goofball use is common, with over half of respondents reporting using heroin and methamphetamine together. Moreover, PWID whose main drug was goofball reported considerable health risks and morbidity, including more frequent injection, femoral and jugular vein injection, public injection, abscesses and skin infections, infected blood clots and blood infections, and endocarditis. They also reported more overdose-related risk including injecting alone and witnessing both opioid and stimulant overdoses. At the same time, the majority of PWID who reported that goofball was their main drug also reported interest in reducing or stopping their drug use. In light of the opioid crisis in the U. Polysubstance use is a global phenomenon, especially the use of opioids in combination with stimulants, and has been associated with high levels of HIV and other negative health outcomes. At present, there is limited epidemiologic data on the unique health effects of combined heroin and methamphetamine use. Due to the shorter half-life of heroin relative to methamphetamine, 12 people using goofball may re-dose when the effects of heroin wane but before the effects of methamphetamine have worn off, potentially leading to the unsafe injection behaviors or overdose. A very high proportion This aligns with dramatic increases in homelessness in the Seattle area. People living outdoors may use stimulants to counter the depressant effects of opioids to remain more aware of their possessions and surroundings. However, people whose main drug was goofball were the most likely to report sharing a syringe or other injection equipment. This is of particular concern given the high HIV prevalence among MSM who inject methamphetamine in Seattle and the potential for connecting high and low prevalence populations. Injecting into the jugular vein was reported by over one-half of people whose main drug was goofball. Another hypothesis is people who inject into the jugular vein have a higher tolerance and seek a faster onset of drug effects. There are limited published data on recent trends in jugular vein injection so it is unclear if this is a local or more widespread phenomenon. The majority of participants reported interest in reducing both their opioid and stimulant use. Medications to treat opioid use disorder are highly effective. The availability of low-barrier buprenorphine treatment in King County has expanded in recent years, including at the SSP where this survey was conducted. The high proportion of opioid users who also use methamphetamine presents a challenge to treatment for opioid use disorder. Research has evaluated the effects of stimulant use on both methadone and buprenorphine treatment and found that treatment retention was lower among patients using stimulants. In the Seattle area, the increase in methamphetamine use has paralleled an increase in methamphetamine-involved deaths, many of which also involved opioids. Moreover, people who primarily use goofball were the most likely to witness opioid and stimulant overdoses, highlighting the critical importance of engaging this group in overdose prevention services. Fortunately, naloxone possession was also highest in this group, suggesting that these efforts have been successful. This analysis has several limitations. Second, the survey was designed to be brief and facilitate program evaluation, so it did not include detailed questions about trajectories and motivations for goofball use. Third, individuals may have completed the survey in both years, which would have resulted in an inflated sample size and standard error, but this could not be measured. Fourth, the analysis included multiple potential correlates of goofball use and did not adjust for multiple comparisons. It is possible that some associations were observed by chance alone. Related to this, there was likely collinearity across some factors, which was not accounted for in the bivariate analyses. Fifth, this survey sampled PWID thus most participants reported injecting goofball as opposed to smoking. The related risks and motivations among people who inject goofball may be different than those who primarily smoke goofball. Finally, this cross-sectional study cannot disentangle the direction of the association between goofball use and its correlates. Prospective studies are needed to determine if PWID who engage in higher risk behaviors are more likely to use goofball, or if goofball use is a factor in increasing risk behaviors among PWID. The high prevalence of goofball use, particularly among younger PWID and those situated in high-risk environments, points to the critical need to identify and tailor harm reduction and other prevention services to this population. The effectiveness of interventions related to the opioid crisis in the U. Moreover, these efforts must consider the profoundly high rates of homelessness among PWID and the intersecting impacts of housing instability on substance use and related morbidities. Continued development and implementation at scale of multifaceted, evidence-based interventions for methamphetamine and heroin co-use has the potential to improve the health and lives of a significant number of PWID. The authors also thank Alexa Juarez for her assistance preparing the manuscript. We are especially grateful to the participants for sharing their time and stories with us. MRG has received research support from Hologic. The authors alone are responsible for the content and writing of this paper. As a library, NLM provides access to scientific literature. Am J Addict. Published in final edited form as: Am J Addict. Find articles by Sara Nelson Glick. Find articles by Kathryn S Klein. Find articles by Joe Tinsley. Find articles by Matthew R Golden. Issue date Mar. PMC Copyright notice. The publisher's version of this article is available at Am J Addict. Open in a new tab. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Health Conditions. Infected blood clot or blood infection, last 12 mos. Sexually transmitted infection, last 12 mos. HIV 3. Pregnancy, last 12 mos. Overdose Experiences. Self-reported opioid overdose, last 12 mos. Naloxone used in overdose situation, last 3 mos. Self-reported stimulant overdose, last 12 mos. Witnessed stimulant overdose, last 12 mos. Men who have sex with men 2. Public 4. Drug Injection Behaviors. Shared other equipment 3 , last 3 mos. Inject in public 4. Drug Treatment Use and Interest. Currently in any treatment for drug use 5.

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