Methamphetamine: An overview of trends in Canada, its role in the drug poisoning crisis and other health issues

Use of stimulants is rising around the world.¹ Methamphetamine use in particular appears to be increasing in Canada, and stimulants are playing a growing role in the drug poisoning crisis. Despite this, people who use stimulants have not historically been prioritized in the design and delivery of harm reduction services. This article will provide a brief overview of trends related to methamphetamine use in Canada, explore evidence about the role of methamphetamine and other stimulants in the drug poisoning crisis and discuss other potential health issues. It will also highlight ways for service providers to better meet the needs of people who use stimulants.

What is methamphetamine and why do people use it?

Methamphetamine is a type of stimulant — a broad category of legal and illicit drugs that increase the body’s physical and mental activity. Methamphetamine can come in powder (e.g., speed), pill or crystal (e.g., crystal meth) forms. It can be smoked, injected, snorted, swallowed, or inserted into the rectum.

The effects of methamphetamine may be experienced differently by different people because of various factors including how, when and where the drug is used, in what dose and how often. Methamphetamine can produce feelings of pleasure, euphoria, alertness, confidence, increased energy and reduced hunger and need for sleep.² For some people, its effects can be calming, but it can also cause nervousness, agitation, paranoia and other adverse effects.² As the effects wear off, people may begin to “crash” and feel tired, depressed and irritated.² Many of these effects are similar to those of cocaine.³ However, a key difference between methamphetamine and cocaine is how long their effects last. It takes about 40 to 90 minutes after use for the amount of cocaine in the body to be reduced by half.⁴ For methamphetamine, this takes between 9 and 11 hours.⁴ As the amount of drug in the body decreases, so do the effects it produces. This means the effects of methamphetamine last for longer, as it stays in the body for longer. Some people may use stimulants continuously over a period of days or weeks, in cycles sometimes described as “binges.”⁴

Methamphetamine is used by a wide range of people for a wide range of reasons. It may be used alone or in combination with other substances, depending on the context and reasons for its use.⁵ People may use methamphetamine for pleasure, to enhance or balance out the effects of other drugs, as well as for other practical reasons such as self-management of ADHD, appetite suppression and to increase alertness.⁶ Some gay, bisexual and other men who have sex with men use methamphetamine to enhance and prolong sex,⁶ as well as for other reasons, such as connecting with people socially and sexually.⁷ Sex workers have reported that stimulants can play a role in helping them stay awake, alert and productive.⁶ People who are experiencing homelessness have reported using methamphetamine as a way to stay awake to protect themselves and their belongings.⁸ However, there is a tendency to view any use of methamphetamine as inherently problematic, which ignores the diverse reasons that people use it. It can also lead to interventions that prioritize stopping or reducing use, rather than providing support to address people’s immediate priorities or underlying needs.

Stimulant use trends: an increase in methamphetamine use

While use of illicit stimulants is low among the general Canadian population,^9,10 surveys of people who use drugs suggest that there has been a sharp increase in methamphetamine use in recent years. A national survey of people who inject drugs found that, while cocaine was the most commonly injected drug, 43% of individuals reported injecting methamphetamine between 2017 and 2019, which is a significant increase from just 6.8% in 2003 and 2005.^11,12 While methamphetamine injection has increased, smoking is the most common mode of methamphetamine consumption in some regions.^13,14 Methamphetamine use has risen alongside a trend towards increased use of multiple substances (called polysubstance use) and the increased presence of synthetic opioids such as fentanyl in the unregulated drug supply.¹⁵

To date, methamphetamine use, availability and harms appear to have increased most notably in Western and Central Canada.¹⁴ Recent reports suggest that methamphetamine use may also be increasing in other areas, including in places where cocaine has long been preferred.¹⁶ The increased availability, the longer duration of the effects, the higher purity and the lower price of methamphetamine, compared with cocaine, may be behind its increasing use.¹⁷ Rising methamphetamine use has also been accompanied by sensationalist media coverage and a strong stigma against people who use methamphetamine.¹⁸ This stigma has led to a range of practices (e.g., increased criminalization, judgment, discrimination and service restrictions) that create barriers to services and can increase the marginalization of people who use methamphetamine.

Stimulants and the drug poisoning crisis

The drug poisoning crisis continues to be driven by the potency and unpredictability of the unregulated drug supply, which is a consequence of prohibition and drug policy.^19,20 When drugs are purchased from the unregulated supply, the risk of poisoning is high as people often cannot know what they are consuming or how strong it is.²¹ While the presence and unpredictability of illicit fentanyl and fentanyl analogues in the unregulated drug supply remain a primary driver of this crisis, stimulants also appear to be playing a role.²² However, our ability to fully understand the role that specific categories of drugs, such as stimulants, are playing in the drug poisoning crisis is limited. This confusion is related to multiple factors, including the following: potential contamination of the drug supply, which means that it may not be possible to know which drugs people intended to use; and the increase in the use of multiple drugs, which means that substances a person used in the final few days of their life could be detected in post-mortem investigations and may or may not have directly contributed to their death.²³ In addition to these confounding factors, only some provinces and territories report on the presence of stimulants in drug poisoning deaths.²⁴

Despite these limitations, it is clear that stimulants are playing a role in the drug poisoning crisis, in terms of both hospitalizations and deaths. Between January 2016 and December 2021, there were over 30,000 hospitalizations for poisoning related to opioids and 13,500 hospitalizations for poisoning related to stimulants.²⁵ The number of deaths involving stimulants appears to be rising. For example, data from British Columbia indicate that the number of drug poisoning deaths involving methamphetamine has increased substantially since 2012.²⁶ In Canada in 2021, the most common stimulants involved in stimulant toxicity deaths were cocaine (62%) and methamphetamine (55%).²⁴

There is also a large overlap between reported stimulant and opioid toxicity deaths. Opioids have been involved in 86% of reported stimulant toxicity deaths, and stimulants have been involved in 59% of reported opioid toxicity deaths.²⁴ Drug poisoning deaths where both stimulants and opioids are involved may be a result of multiple factors. One of these factors is the intentional combining of opioids and stimulants when using drugs. Use of multiple substances is a growing trend. Combining heroin and cocaine to inject has long been a common practice among people who use drugs and is sometimes called a speedball. However, the practice of combining methamphetamine with synthetic opioids, such as fentanyl, is less well understood.^27,28 This combination can involve using the drugs at the same time (sometimes called a goofball), or using one drug after the other.²⁹ There are multiple reasons why people may combine methamphetamine and opioids, including:^13,28,30,31

• to prolong the euphoric effects of opioids or avoid opioid withdrawal
• to produce more desirable effects than can be achieved with either drug alone
• to attempt to counteract one drug’s negative effects or to balance each drug’s effects out
• to self-medicate or manage health issues
• to save money (e.g., methamphetamine is often cheaper than fentanyl and can extend fentanyl’s effects, which reduces the need to buy more)

Some people report using methamphetamine alongside opioids because they erroneously believe that it reduces the risk of opioid overdose.³² However, combined use of stimulants and opioids has been associated with increased risk of overdose and other harms. This may be because stimulants speed the body up, increasing the heart’s need for oxygen, while opioids slow the breathing rate and reduce the amount of oxygen the body can get.³³ It is also possible that one drug may mask the signs of an overdose from the other drug, leading to a delayed response by other people who may be present.^32,34 In combination, stimulants and opioids can increase the risk of overdose due to respiratory depression and heart attack.³⁴

Another factor that may play a role in the increasing involvement of stimulants in drug poisoning deaths is contamination within the illicit drug supply. In samples that have been analyzed, opioids such as fentanyl have occasionally been found in drugs that were expected to be stimulants. This contamination may be more common in Western Canada than Eastern Canada. In 2018–19, fentanyl was found in 10% of methamphetamine and 7% of cocaine samples in British Columbia, compared with 3% of stimulant samples nationally and 1% of samples in Quebec.³⁵ This cross-contamination is likely due to accidents in packing or processing,³⁶ but it creates particular dangers for people who use stimulants: if someone does not have a tolerance for opioids, using illicit fentanyl can be fatal.

Overamping and other potential stimulant-related health issues

People who use stimulants have not historically been prioritized in the design and delivery of harm reduction services. Given the increasing use of methamphetamine and the continued use of cocaine among people who use drugs, it is important for service providers to be aware of potential health issues and other harms that can be related to stimulants so that they can provide and/or link service users to appropriate care. Health issues can occur regardless of the substance’s route of administration.

Stimulant overamping

Overamping refers to a range of physical and psychological symptoms associated with stimulant overuse or overdose. Stimulant overamping is not well understood and there is variation in how people experience symptoms.¹⁷ Physical symptoms can include rapid heart rate, trouble breathing, high body temperature or sweating, muscle spasms or jerking limbs, seizures, going in and out of consciousness, chest pain and heart attacks.^17,37 Psychological symptoms can include agitation, confusion, anxiety, paranoia and hallucinations.^17,37 For some people who use stimulants, these symptoms may be related to other factors, such as a need for sleep.³⁷ People may not recognize signs of overamping or seek medical attention, except in severe or life-threatening cases.¹⁷ A lack of understanding and the wide range of symptoms can make it challenging to recognize and respond to overamping.¹⁷

Emergency medical attention may be required to respond to overamping, particularly in the event of life-threatening symptoms such as heart attacks, strokes or seizures. For less severe cases of overamping, responses can include reducing sensory stimulation (e.g., going to a quiet, dark room); placing a cold, wet towel on the forehead and under the arms; encouraging slow, deep breaths; talking the experience through to help the individual calm down; and going for a walk or jog).¹⁷ Offering a drink (e.g., water, orange juice) or snack (e.g., freezies) can help people to cool down and keep them hydrated.³⁸ Naloxone does not reverse stimulant overamping, but it is safe and can help if someone has used a mix of drugs. Other approaches, such as putting the person in a cold shower or encouraging them to use other substances (e.g., opioids, benzodiazepines) to counteract the effects of stimulants, are not recommended and may cause harm.¹⁷

Psychosis

Stimulant use or withdrawal from stimulants can be associated with experiencing symptoms of psychosis.³⁹ Psychosis can involve paranoia, suspiciousness and hallucinations, which can lead to confusing or erratic speech or behaviours. Stimulant-related psychosis can sometimes last for days, but it usually resolves once the substances have left the body.⁴⁰ If an individual is experiencing psychosis, it is important to follow their lead: ask them what they need in that moment, rather than assuming or guessing.⁴¹ Avoid suggesting that their experience is not “real,” and avoid judging, threatening or arguing with them.⁴¹ Try to give them space, be empathetic about how they are feeling and talk their experiences through with them, if they want to.⁴¹

Impact on sleep and nutrition

Stimulant use can affect people’s sleep and nutrition. Using stimulants can help people to stay alert, reduce their need for sleep and supress their appetite. Withdrawal from stimulants is also associated with sleep disruptions and reduced quality of sleep.^42,43 When stimulants are used in “binges,” people may not eat or sleep for extended periods of time. These impacts can be exacerbated by many factors such as an individual’s food security, their income, their housing status and their eating and sleeping patterns.⁴⁴ Service providers may wish to consider ways in which they can support people who use stimulants to access nutritious, protein-rich food and safe places to rest.

Hepatitis C, HIV and other sexually transmitted and blood-borne infections (STBBIs)

Stimulant use is associated with increased risk of hepatitis C, HIV and other STBBIs. This is because the ways and contexts in which people use stimulants can increase their chance of getting blood-borne infections. These infections can be passed by sharing drug use equipment or through sexual activities that may take place within the context of substance use. The use of substances such as methamphetamine in the context of sex has been associated with increased likelihood of participating in activities that have a higher chance of STBBI transmission (e.g., sex with multiple partners, condomless sex, rougher sex due to reduced sensitivity to pain, sharing of equipment). Distributing safer sex supplies (e.g., condoms, lube) alongside safer substance use equipment (e.g., safer injecting, smoking and snorting equipment) and providing related education may support people to reduce the chance of infections.

Stimulant use disorder

There are very limited treatment options for people with a stimulant use disorder. Psychosocial approaches remain the standard of care for the treatment of stimulant use disorder in Canada.⁴⁵ Of these, contingency management, which involves providing incentives (e.g., cash, gift cards or other prizes) for continued abstinence, seems to be the most effective.^4,46 Research is ongoing into the potential for medication-based treatments for stimulant use disorder. A recent systematic review and meta-analysis concluded that strong doses of prescription amphetamines show promise in treating stimulant use disorder, especially cocaine use disorder.⁴⁷

Implications for service providers

Given the increasing use of stimulants in Canada and the harms associated with stimulant use, particularly methamphetamine, service providers should examine how their services are meeting the needs of people who use stimulants, alone or with other substances. There are many ways that service providers can consider the needs of people who use stimulants as they plan and deliver programs and interact with service users.

Service and program planning

Service providers should ensure that people who use stimulants are involved in all aspects of the design, delivery and evaluation of services and programs that aim to serve them. This includes employing people with lived or living experience and providing equitable compensation. There are several other actions that service providers can also consider taking as they plan services and programs:

• Understand the potential role(s) that stimulants play in a given community (e.g., to enhance sexual pleasure, to promote alertness, to balance another drug’s effects out) and design services with related needs in mind (e.g., offering safer sex supplies, providing safe spaces to rest, providing nutritious food). This includes ensuring that services are culturally relevant, culturally safe and trauma informed.
• Recognize the ways that people in their community use stimulants (e.g., smoking, injecting, snorting, inserting into the rectum) to ensure that they are providing safer drug use equipment for their service users’ preferred routes of administration and that supervised consumption sites are implemented to accommodate these routes.
• Evaluate how their physical sites and service models meet a range of potential needs for people who use stimulants. This can include providing calm spaces with reduced sensory stimulation to support overamping responses, providing secure storage lockers and other spaces for people to store and organize their belongings, ensuring that spaces are free from hazards and providing spaces for people to do activities (e.g., fixing bikes, using adult colouring books) that can help relieve anxiety related to stimulant use.⁴¹
• Develop policies and organizational culture that support both harm reduction approaches and harm reduction workers’ wellness. This can include a range of organizational steps,⁴⁸ as well as developing clear policies, taking team-based approaches and engaging in continuous debriefing to ensure staff are prepared to respond to challenging situations.

Service delivery

When delivering programs and services, service providers should do the following:

• Continue to provide services and support to all individuals, regardless of whether stimulant use is suspected. This includes not denying individuals access to services if they are agitated or in distress, not blaming them for these experiences or attempting to coerce them into stopping using stimulants.
• Prioritize safety for all service users and staff. Where possible, avoid imposing service restrictions as they can raise barriers and produce harms for individuals and the community.
• Understand the range of reasons why people may use multiple substances. When discussing safer substance use, this can involve recognizing and making space to discuss the benefits people experience from mixing drugs, rather than focusing only on potential risks.
• Avoid stigmatizing language, practices or assumptions related to stimulant use.
• Distribute equipment for safer substance use and safer sex supplies that meet service users’ needs.
• Provide referrals to harm reduction, sexual health, primary care, housing, treatment programs, safe supply programs and other services, upon request by service users.
• Provide naloxone kits and education about responding to opioid overdoses and stimulant overamping to all service users, regardless of their substance of choice.

Working with individuals who use stimulants

Owing to a range of structural and social factors, people who use stimulants may experience times of distress or crisis that can be challenging for them to manage and for service providers to respond to. There is no single clear-cut approach to working with individuals who are experiencing a crisis, regardless of whether stimulants are involved. Service providers can consider doing the following:⁴¹

• Build relationships with service users during times of non-crisis to promote trust and build rapport.
• Seek training on responding to mental health crises and conflict de-escalation.
• Improve your personal knowledge and understanding of factors (e.g., overamping, need for sleep) that may be related to paranoia, psychosis and other challenges for people who use stimulants.
• Follow the individual’s lead when they are experiencing distress and check in with them about what they might need.
• Mirror the individual’s body language, empathize with their concerns and talk their experiences through with them, without contradicting their experience of reality or denying them help.
• Allow individuals to go to a quiet, calm area with easy and clear exits, if possible.
• Recognize your own boundaries and capacity and seek support from other experienced team members, if necessary. This can include team-based approaches and continuous debriefing to improve responses to future incidents.
• Remain open and honest with any individual experiencing crisis, including letting them know if emergency services have been called.

Additional resources

For service providers

• Party Time
• St. Stephen’s Community House: Crystal Methamphetamine Strategy
• Safer Substance Use Video Series

For service users

• Responding to an opioid overdose, Responding to stimulant overuse and overdose
• Safer Crystal Meth Smoking
• Safer Crack Smoking

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About the author(s)

Magnus Nowell is CATIE’s knowledge specialist in harm reduction. Magnus has previously worked in harm reduction research, community organizing and housing. He has a master’s degree in health promotion.

Externally reviewed by: Dr. Jane Buxton & Sanda Kazazic