“I Can Combine Those Things to be a Superhero” a Qualitative Study of the Motivations for High-Risk Polysubstance Use

Abstract

The current study aimed to understand motivations of high-risk polysubstance use. Semistructured interviews were conducted in New York City with 20 individuals with frequent recent polysubstance use. Two analysts coded the interviews (κ = 93.97). Five themes related to motivation for polysubstance use were found: (1) balance, prolong, or enhance effects, (2) self-medicate physical ailments, (3) cope with emotional distress, (4) drug-induced cravings, and (5) responding to social contexts. Individuals reported simultaneous or sequential co-use to balance, prolong or enhance a ‘high’ (theme 1). Participants engaged in polysubstance use to alleviate withdrawal symptoms, to induce sleep and self-medicate physical pain (theme 2) and to provide relief from emotional distress (theme 3). Other themes included drug-induced cravings (theme 4) and responding to social contexts (theme 5) including both social situations and economic availability. Motivations for polysubstance use may provide important insight into harm reduction and treatment settings solutions.

Introduction

Polysubstance use refers to the co-use of multiple substances; used simultaneously or sequentially, and is a critical public health concern due to its association with increased overdose fatalities (Bunting et al., 2023; Liu, 2021; O’Donnell et al., 2021). Overall, individuals engaged in polysubstance use patterns known to contribute to overdose (e.g., co-use of stimulants and opioids, benzodiazepines and alcohol, etc.) are a vulnerable subpopulation within the greater population of persons who use drugs. Specifically, individuals who engage in polysubstance use involving high-risk combinations are typically younger, have multiple physical and mental health co-morbidities, and are more likely to have contact with criminal legal systems (Bunting et al., 2020; Karamouzian et al., 2022; Palis et al., 2022). The goal of the current qualitative study was to explore motivations for high-risk polysubstance use, with high-risk conceptualized as frequent recent, engagement in polysubstance use patterns known to contribute to fatal overdose.

An understanding of the desired intention or facilitating force behind an individual’s use of substances can provide important insights to individualized and appropriate interventions (Rigg & Ibañez, 2010). Previous research has found motivations of use to be associated with potentially more severe and persistent substance use disorder (Crum et al., 2013; Mariani et al., 2014; O’Hare & Shen, 2012). Motivations provide insights to what an individual anticipates their substance use will provide to them. These expectations can make substance use more reinforcing. In mono-substance use studies, most notably cannabis and alcohol, certain motives are associated with subsequent increased substance use (Lee et al., 2022). Polysubstance use also complicates treatment outcomes (Chen et al., 2011; Tsui et al., 2020; Williamson et al., 2006). For example, nearly half of individuals in a methadone treatment program reported they started, increased, or resumed benzodiazepine use after entering methadone treatment, indicating a missed opportunity for intervention during mono-substance focused treatments (Chen et al., 2011). An understanding of the motivations for polysubstance use may, therefore, provide critical insights to inform and improve public health surveillance, treatment, and harm reduction services.

Previous research has found that generally, individuals mix substances for the synergistic and preferred effects that are created when substances are combined over the effects created by mono-substance use (Valente et al., 2020). In a rapid review of the literature from 2010 to 2021, Boileau-Falardeau and colleagues (Boileau-Falardeau et al., 2022) identified eight common motivations for polysubstance use across thirteen qualitative studies, including alleviating withdrawal symptoms, prolonging a ‘high,’ balancing effects, counteracting effects, enhancing a ‘high,’ reducing use, mimicking other substance use, and to self-medicate physical pain. The review included studies that were specific to substance use combinations (e.g., motivations for persons who use cocaine with other drugs). For example, stimulants and opioids are often taken together concurrently or simultaneously to enhance the effects of each drug (Ellis et al., 2018; Leri et al., 2003). With more variation for motivation, opioids and benzodiazepines may be combined to reduce anxiety generally or to help alleviate withdrawal symptoms after periods of heavy opioid and stimulant use (Chen et al., 2011; Motta-Ochoa et al., 2017). Consideration of the motivations of timing of polysubstance use (sequential, the use of one substance followed by another in short intervals, or simultaneous, two or more substances used at the same time with little to no gap in time) may also provide important insights. Limited research has explored route of administration patterns by type of polysubstance use, but simultaneous patterns may be overall riskier (Mccabe et al., 2006; Subbaraman & Kerr, 2015) and motivated by desires to achieve unique and reinforcing effects (Liu et al., 2018).

Given that previous research has focused on motivations for using specific substances, an understanding of how these motivations differ between substance-specific combinations and broader multiple substance use behaviors may improve our ability to effectively address high-risk substance use behaviors. Further, examining motivations in a broad population of persons who drugs supports the scientific goal of replication science (Nosek & Errington, 2020; Tuval-Mashiach, 2021). The goal of this research was to understand motivations of polysubstance use among individuals engaged in high-risk co-use patterns, to see if there were universal motivations of use (regardless as to primary substance) and if motivations differed by type of polysubstance use (sequential or simultaneous).

Methods

Data were collected in New York City via in-person semi-structured interviews from September 2021 to March 2022, as part of a larger project on the development of a novel polysubstance assessment tool. Participants were recruited to the sample via convenience methods with an IRB-approved flyer; through referral from staff at a harm reduction agency, referral from other research studies at the University, and word of mouth. Interested individuals were instructed to contact the study team to screen for eligibility. Inclusion criteria were: (1) 18 years or older, (2) able and willing to provide informed consent, and (3) self-report polysubstance use of at least 5 days in the past 30 days. For those released from jail or prison within the past 30 days, eligibility was 5 or more days in the 30 days prior to incarceration. During screening, polysubstance use was assessed with a question from the Addiction Severity Index (McLellan et al., 1992), “In the past 30 days, how many days did you use more than one substance per day, including alcohol?” A summation score of days of use of several substances was calculated. Substances included: alcohol, heroin, methadone or buprenorphine not prescribed/used nonmedically, opioid or pain killers not prescribed/used nonmedically, sedatives not prescribed/used nonmedically, cocaine or crack, prescription stimulants not prescribed/used nonmedically, methamphetamine, cannabis, hallucinogens, inhalants, and kratom. Tobacco was not considered a substance for eligibility. Participants were excluded from participation if (1) they were currently incarcerated in a prison, jail, or other institution and/or (2) their self-reported polysubstance use was limited to co-use of alcohol and marijuana given the study’s focus on co-use patterns that contribute to overdose. Eligible and interested individuals were scheduled for an in-person interview at the study office. During the single study visit, participants provided verbal consent and were provided a key information sheet.

A sample size of 20 was set a priori, related to the larger project goals and budget. Interviews were conducted by the principal investigator (n = 10, AMB) and a trained research assistant (n = 10, AF). The interviews began with the collection of brief demographic information. Then, the researcher asked the participant about their past 30-day substance use using questions from the Addiction Severity Index (McLellan et al., 1992). The qualitative interview began with research staff asking participants to detail an average week of substance use and probed participants about their specific sequence of use, route of administrations, and motivation for co-use including the feeling of two or more substances combined as compared to mono-use via the question, “Why did you use [SUBSTANCE] and [SUBSTANCE] together?” and “If you had to describe your reason for using [SUBSTANCE] and [SUBSTANCE] in one or two words, what would it be?” At the end of the interview, participants were asked to identify the primary motivation for their combined use of substances.¹ Interviews were audio-recorded and lasted an average of 25 minutes (R: 11–45). Participants were compensated $50 via a debit card for their time. Study procedures were approved by the NYU Langone Institutional Review Board and protected by a Certificate of Confidentiality.

Analysis

Audio recordings were transcribed by a professional transcription service. Two trained research staff members proofed the completed transcripts by listening to the audio and confirmed the transcription was accurate or made corrections as needed.

A codebook of the motivations for polysubstance use was created via a codebook meeting with the principal investigator and the two research staff (AF, BG) who completed proofing (one of whom completed 10 of the interviews, AF). Upon completion of proofing, the team examined the motivations compiled by the Boileau-Falardeau et al. (2022) literature review to inform the initial codebook. Together, the team decided which motivations from the Boileau-Falardeau review were appropriate to include as codes, based on their familiarity with the interview content. Additional codes specific to the study population were also added. The preliminary codebook had 23 codes, 15 of which were directly related to motivations for polysubstance use. The other codes were related to themes not included in this manuscript such as overdose and treatment experiences. The two research staff members coded two interviews separately, then the study team met to review concordance. This process was repeated for the first ten interviews. The coders noted two additional codes to add, related to overdose and preference for polysubstance use. As concordance in application of the codes was high, the coders coded the subsequent interviews on their own and met to compare remaining transcripts and found little to no discrepancies; any differences in coding application were resolved through discussion. After coding, thematic analysis of the codes was conducted. Specifically, the principal investigator reviewed codes related to motivation of polysubstance and assessed the (1) quality and content of each code to determine if a code was significant to the research question, (2) identification of themes within codes, (3) overlap across codes to identify the themes, and (4) specific substance use patterns such as sequential or simultaneous and the substances involved. Some themes retained the name of the initial code given the targeted coding approach. Research staff used NVivo 12 software for analysis (QSR International Pty Ltd., 2018). The final kappa between coders for the included codes was 93.97.

Results

Participant demographic and substance use characteristics are presented in Table 1. Participants were on average 50 years old (R:21–77), the majority were Hispanic (45%) and/or Black (30%), and males (85%). Participants mostly reported they were housed (85%) and were unemployed (55%). Participants reported an average of 17 days of polysubstance use in the past 30 days. Motivations for polysubstance use are presented in Table 2. Motivations for use were considered generally as well as specific to sequential (i.e., substances used in patterns throughout the day) and simultaneous (i.e., substances taken together or back-to-back) use. Motivations were clustered into five overarching themes: (1) balance, prolong, and enhance effects of substances, (2) self-medicate physical ailments, (3) coping with emotional distress, (4) drug-induced cravings, and (5) responding to social contexts.

Table:1.

Demographics, n = 20.

	%
Age ($\overline{\text{x}}$, SD)	50 (13.3)
Male	85
Hispanic	45
Race
Asian	5
Black	30
White	30
Othera	35
Education
High school graduate or less	75
Some college	25
Living situation
In a shelter	15
With friends/family	10
In apartment/house	75
Employment status
Full time	10
Part time	15
Disabled, receiving SSDI	20
Unemployed	55
Substance use, past 30 daysb
Alcohol	85
Heroin	60
Prescription opioids	50
Methadone or buprenorphine	25
Sedatives	40
Cocaine or crack	70
Prescription stimulants	15
Methamphetamine	5
Cannabis	80
Hallucinogens	10
Inhalants	10
Kratom	0
Tobacco	85
Number of days of polysubstance use ($\overline{\text{x}}$, SD)	17.3 (9.8)

Note. $\overline{\text{x}}$, SD = mean, standard deviation for continuous variables.

^aIndividuals selecting ‘other’ race identified as Hispanic, with no other race.

^bsubstance use variables refer to use nonmedically.

Table 2.

Motivations for High-Risk Polysubstance Use (n = 20).

Theme	Code	Prevalence (%)	Substance patterns
Balance, prolong, or enhance effects	Balance effects- sequential	55.0	Primarily cocaine + alcohol or heroin
	Balance effects- simultaneous	30.0	Cocaine + heroin
	To prolong or enhance a high-sequential	20.0	Multiple
	To prolong or enhance a high-simultaneous	35.0	Multiple
Self-medicate physical ailments	To alleviate withdrawal-sequential	45.0	Cocaine, methadone, + heroin
	To induce sleep- sequential	45.0	Primarily cannabis
	Self-medicate- physical pain	25.0	Opioid + other drugs
Cope with emotional distress	Cope with emotional distress	80.0	Multiple
Drug induced cravings	Drug craving	20.0	Alcohol + other drugs
Responding to social contexts	Social contexts	65.0	Alcohol + other drugs, multiple

Theme 1: Balance, Prolong, and Enhance Effects

Participants reported sequential and simultaneous use of substances to balance the effects of substances taken or to prolong or enhance their ‘high.’ The majority of use was motivated by a desire to balance the effects of the substances taken. Participants primarily discussed the sequential use of stimulants, specifically the use of cocaine to deal with the sedative effects from alcohol or heroin:

“Well, usually the alcohol gets me ready for the coc[aine] ’cause I’ll be having a little bit woozy. Then the cocaine is a pick-me-up..…You know? I’m woozy and stuff like that, so I enjoy having the cocaine and, you know?…Just a little jolt or whatever. Like I would walk to [neighborhood] to get it instead of getting on the bus.”

“The cocaine, when I start feeling like I’m drowsy [from heroin], that I start feelin’ like I’m nodding and I’m—so I use the cocaine so I can wake a little bit up. I don’t usually use that much cocaine like that—not that much.”

Alternatively, some individuals noted negative effects (e.g., anxiety, over-energized) from stimulants and the sequential use of other substances to balance or counteract those feelings:

“In other words, if I drink and then I smoke the crack, then it will be all right, but if I don’t, I get really anxious. The crack makes me very anxious.”

“I won’t do coke by itself. I will do just weed and just alcohol, but I wouldn’t do coke by itself. I don’t wanna constantly keep moving too fast. The weed would balance it out. ‘Cause the coke is a stimulant. The weed is a depressant.”

Some participants combined cocaine and heroin simultaneously, often referred to as a ‘speedball,’ and reported the combined use balanced effects of each substance. As described by one participant who used speedballs as, “…like a elevator ’cause it goes up and down for a while. That’s it. It keeps me calm. ”

Participants also reported engaging in sequential polysubstance use to prolong or intensify the subjective feelings of a ‘high,’ as exemplified in the illustrative quote below:

“Interviewee: I have had ketamine just alone, but for a short time, and then I would smoke [cannabis] after.

Interviewer: Okay. Why do you think that is?

Interviewee: First of all, ‘cause I like smoking. Second of all, I think they mix pretty well together. Smoking on ketamine enhances the psychedelic aspect. Also, the dissociative aspect. Yeah, you kinda just leave your body. Yeah, I’d say that.”

Notably, the enhancement of a ‘high’ could also be to create mellow, as opposed to euphoric, effects, such as one participant who was asked to describe the feeling of smoking cannabis alone to cannabis with crack:

“It’s more of a mellow high. It’s not like a—Yeah, it’s not like an intense high. If you smoke crack by itself, it’s an intense high. The first time I ever did it I did with weed, somebody was smoking it, and I was like, let me get some of it, and I smoked it. I enjoyed it. I enjoyed the high. It wasn’t like I was peek-a-booing and running around and lookin’ for shit on the ground, it wasn’t none of that. I just enjoyed the high. It was like okay, what it was doin’…a cocaine high by itself to me is garbage.”

The details provided by this participant are interesting to consider, as they appear to distance themselves from cocaine use in their statement that they do not really enjoy the subjective feeling of cocaine. However, when combined with cannabis they felt it is a “mellow high” that is more pleasurable than smoking cannabis or using crack alone. Participants also described how some substances simply combined well to create the desired subjective state, as in the case of one participant who combined prescription stimulants (nonmedical) and cannabis:

“I feel like you’re more emotionally intelligent when you’re smoking [weed]. It’s just nice ’cause then you’re quicker too ’cause weed slows me down. If I add Adderall I can combine those things to be a superhero, I don’t know.”

Overall, a desire to balance, prolong, and enhance one’s subjective state was a primary motivation for individuals engaged in polysubstance use.

Theme 2: Self-Medicate Physical Ailments

Participants reported engagement in polysubstance use behaviors to achieve perceived ‘medicinal’ effects and provide relief from physical ailments. Individuals cited several reasons for co-use of substances related to their desire to alleviate symptoms of withdrawal, to induce sleep, and self-medicate their emotional distress and physical pain. Only individuals with sequential use, as opposed to simultaneous patterns of use, reported engaging in polysubstance use to alleviate withdrawal symptoms. Participants in methadone programs often reported that sequential patterns of use were necessary to avoid withdrawal that would occur from their use of cocaine:

“Interviewee: Yes but sometimes you smoke a lot [of crack], it kills the methadone. It kills the methadone and that’s when I’ll probably get it a bag and sniff that.

Interviewer: You start to feel sick? You start to have withdrawals almost?

Interviewee: Sweats, yeah. That’s let me know that I’m smoking too much and then I’ll probably go get a bag of heroin.”

Participants in methadone programs who used cocaine would state that the use of cocaine would “eat up” or “kills” their methadone and cause them to go into withdrawals, creating a need for them to use heroin later in the day. Participants also reported sequential use of substances, primarily cannabis, to induce sleep. For some, their inability to sleep was sometimes related to their earlier drug use (e.g., use of stimulants) or related to anxious thoughts.

A few participants also suffered from physical pain and preferred combining substances to fully alleviate their physical symptoms. For example, a participant who used speedballs stated:

“If I’m just in pain, I know I need to get rid of the pain, cocaine takes away the pain…Like I said, my desired result is to feel good while I’m taking away the pain. That’s why the speedball is what works for me.”

The above quote was related to speedball use, and opioids in combination with other substances such as cocaine or alcohol were primarily implicated in individual’s attempts to relieve physical pain.

Theme 3: Cope with Emotional Distress

Nearly all participants (80%) indicated significant emotional distress and a motivation to combine substances to cope, despite the fact the interview guide did not query or specifically probe for emotional trauma. One participant who used heroin, cannabis, and alcohol daily stated:

“It’s just difficult. I used, because I just can’t, and I have trouble—I actually have trouble dealing with reality, I suppose… I just feel that I can’t deal with myself the way I am, and I need to medicate.”

As another participant stated:

“It helps me relax, it does, ‘cause if I had to really think about what life entails, I’d probably lose my mind, like knowing what life entails.”

Other participants shared recent emotional traumas such as deaths of family members as turning points in their polysubstance use, and an overall struggle to cope with, as one participant stated, “the realness of the world.” Related to emotional pain, a participant shared:

“Yeah. I wouldn’t say I use [alcohol and heroin] to get extremely high, but I use to forget—I’m like, I don’t care anymore, Jesus, you know…I just want to forget about everything, and why did this happen to me? Maybe I’m feeling sorry for myself. I don’t know. I could have prevented it. I didn’t choose to be this way.”

Numbing of emotional pain or avoiding memories of previous or ongoing traumatic experiences were frequently cited motivators of combining substances.

Theme 4: Drug-Induced Craving

While less often cited as a motivation, participants also engaged in polysubstance use due to drug craving that one substance induced for another. One participant explained: “One goes with the other. If I’m drinking, I think about the heroin. If I’m not sniffin’, I think about the alcohol. ”

Cravings seemed to be a more common polysubstance use motivation among individuals whose patterns of use involved alcohol, as further illustrated by the following participant:

“Then when I drink the alcohol, it makes me wanna do more. If that makes any sense. It makes me wanna do other things like the Oxycontin, or maybe call somebody, say, “Hey. Do you have an extra Ambien?” I just wanna relax.”

Participants also referred to cravings for cigarettes, either pre or post alcohol or cocaine use. However, tobacco use was not a primary substance explored in this study.

Theme 5: Responding to Social Contexts

The social contexts that participants operated in, and their social networks also influenced their specific polysubstance pattern engagement. Several participants reported not using alcohol regularly but engaging in social use, primarily on weekends with friends. Usually, they did not alter their regular pattern of substance use but rather added alcohol into the mix during these social times. There were high rates of unemployment in the current sample, and participants also discussed the social sharing of drugs based on economic availability among close friends, and how that they may influence the substances they combine at any given time:

“I got a few dollars in my pocket. Yeah. Basically beer is the first thing. Then if I bump into my friend, usually he’s got some dope. You know? Or either we’ll go there, and he has to call the guy up and wait around. It’s a pain-in-the-ass. The cocaine, if I’m gonna get the cocaine, it’s right there…Just basically I’d start with the alcohol usually, but I don’t do cocaine every day or the dope every day. Well, unless it’s available. You know what I mean?….yeah, it’s hard to answer some of those questions actually. ‘How many do you do in a week?’ It depends on the money. I mean, you know?… If I had money. Yeah. If I call my friends and say, ‘Are you coming by today?’ Sometimes if he doesn’t come by, I’ll go drop by. He’ll come downstairs and, you know?”

Participants also shared that their general pattern of use did not change, but the amount they would use changed depending on the social context:

“The weekends, just is a bigger thing because I’m partying, hanging out. You know what I mean? At the club. At family gatherings, you know friends, you know gatherings, you know, things like that… I use more alcohol and drugs, both more.”

“[when I’m by myself] the only difference being I’ll probably do two and a half [bags of heroin], a half a Xanax and maybe no marijuana, but definitely coffee, cigarettes and less of indulging in, like, more bags [of heroin]. The more people the more bags.”

The above participant detailed that they usually had six to seven bags of heroin shared among two to three friends when socializing as compared to days of solo use that were typically limited to three bags. Social context was important insofar as individuals’ socialization (e.g., who they were with) and the availability of drugs related to economic circumstances, or the two factors colliding (e.g., increased social group size creating a shared pool of resources).

Discussion

The current research examined the motivations of polysubstance use among a population of persons engaged in high-risk substance use combinations. Motivations of co-use were primarily related to the goal of enhancing the subjective effects that combinations provided, and participants also cited physical and emotional relief, drug craving, and social contexts as motivations for their polysubstance use. The findings assist in validating the motivational categories which have been found in previous research with populations who shared a primary substance of use (Mahu et al., 2021). Additionally, the current study found two themes that were not identified in the Boileau-Falardeau review of qualitative studies: coping with emotional distress and responding to social contexts. Understanding individual’s motivations for polysubstance use has important implications for harm reduction and treatment.

Individual’s subjective experience of substances and the order of their use was critical to their goals to balance, prolong, or enhance effects. The differences in subjective experience was apparent with the order of cocaine use. Some individuals preferred the use of cocaine to energize themselves after taking central nervous system depressants while others engaged in polysubstance use involving cocaine because they had negative affective experiences from cocaine use alone. Notably, some individuals combined cannabis and cocaine for a reduced excitant effect; however, cannabis strains vary widely and increased THC potency may actually reproduce stimulant effects rather than alleviate them (Childs et al., 2017; Hunault et al., 2014). It is also notable that some participants reported that the use of substances simultaneously, rather than sequentially, provided a desired balance effect. Most often this reinforcing effect has been found in research of opioids and stimulants (Crummy et al., 2020; Leri et al., 2003). Yet a gap remains in how to address the reinforcing effects in treatment settings. For example, as shared by participants in this study, an individual’s cocaine use may be secondary and only ‘needed’ as a result of their alcohol or heroin use. For these participants it is plausible that a focus in treatment on their opioid or alcohol use may cause reductions in their cocaine use. Alternatively, participants who reported they enjoyed combining substances due to preferential subjective effects may need interventions that target the pharmacologically rewarding effects of the use of multiple substances through a focus on dopamine response (Compton et al., 2021).

The engagement of polysubstance use was also motivated by the desire to achieve emotional relief. Unprobed by the interview, a majority of participants noted significant losses in their lives (e.g., death of family members, overdoses). While trauma may be a motivating factor for all individuals with a substance use disorder given elevated prevalence (Giordano et al., 2016), the use of substances to cope may be acute among persons engaged in polysubstance use. Persons engaged in polysubstance use are more likely than individuals without co-use to have post-traumatic stress disorder (Kearns et al., 2019; Martinotti et al., 2009; Mills et al., 2006; Salgado et al., 2007). However, it is unclear how subjective states or desired effects via certain combinations may relate to extreme distress and avoidant coping (Ullman et al., 2006). Despite the high prevalence of co-morbidity, models to simultaneously treat substance use and mental health disorders are relatively lacking and scarcely implemented (Najavits et al., 2020; Najavits & Hien, 2013). Incorporating mental health into harm reduction settings could be particularly helpful for individuals engaged in high-risk polysubstance use (Bartram, 2021; López-Castro et al., 2024).

Self-medicating physical ailments was an additionally salient motivation. Individuals sought to alleviate physiologic withdrawal symptoms, induce sleep, or relieve physical pain. A unique finding in the current study was the sequential use of cocaine and heroin to relieve withdrawals for individuals receiving methadone. Sustained cocaine use during methadone treatment is quite common (Cone, 2012; Dobler-Mikola et al., 2005; White et al., 2014), and can be motivated by the sedative effects of methadone (McNeil et al., 2020). While the prevalence of and relationship between cocaine and heroin use for methadone maintenance patients has been explored, the current study is one of the first known to articulate participants subjective feeling state as to why this combination is necessary (i.e., feeling that cocaine ‘eats’ the methadone and causes withdrawals that are then alleviated by heroin use).

Some participants reported polysubstance patterns related to drug-induced craving; that is one substance triggered a craving for another- specifically citing the role of alcohol in their cravings. Previous research found that individuals drank more alcohol on days with higher cocaine or heroin craving (Preston et al., 2016). While craving was mentioned as a motivation, all interviews that mentioned craving also cited other motivations for polysubstance use, indicating that craving may be an important, but not sole or necessarily driving, motivator. It is also interesting that participants cited the desire to relieve physiologic withdrawal symptoms as a motivator for polysubstance use, yet their descriptions of drug-induced craving were distinct from their descriptions of polysubstance use inducing or alleviating withdrawal symptoms. These nuances could be further explored in research, potentially with a discourse analysis approach.

Lastly, social contexts were frequently cited as driving polysubstance use patterns. Specifically, social engagements and drug availability had an important effect on the polysubstance patterns that individuals engaged in. Social motives, sometimes referred to as external motives, have been found most often for alcohol use (Bresin & Mekawi, 2021; Cooper et al., 2016; Mahu et al., 2021). Participants in the current study shared how certain patterns only occurred during social situations, primarily increased alcohol use, or how social situations changed the amount of substances they consumed due to increased availability. While previous research has highlighted the importance of social networks on substance use (Bohnert et al., 2009; Neaigus et al., 2006; Rosenquist et al., 2010), there are key considerations for harm reduction specific to polysubstance use that can be considered. The role of social networks as described by participants in this study may heighten overdose risk. Participants stated they engaged in heavier or different patterns of substance use in certain social environments, and this heightens the risk of an overdose. The addition of alcohol, a central nervous system depressant, can also further increase risk for participants given their baseline polysubstance use. Alcohol is sometimes overlooked as a risky substance when individuals are engaging in substance use of stimulants or opioids (Bunting et al., 2023), however, national data indicate an increased prevalence in the number of opioid overdoses that co-involved alcohol (Tori et al., 2020). Data specific to this study’s location of New York City, indicated 42% of opioid overdoses in 2020 co-involved alcohol, and the prevalence was higher among fentanyl overdoses with 80% co-involving alcohol (NYC Health Dept, 2021). It remains unclear, however, how harm reduction approaches consider the addition of alcohol use among individuals at risk for overdose. A possible area to explore for public health messaging would include campaigns that highlight the increased risk of overdose when adding alcohol to other drug use, and situating these campaigns within social situations. The potential for heightened risk also illustrates the critical importance of targeting social networks of people who use drugs in naloxone distribution (Bennett et al., 2022).

The current study was conducted in a single city with convenience sample methods, and findings should be considered with this sampling in mind. A limitation of the current research includes the prevalence of cocaine use and the limited use of methamphetamine use in New York City. While crystal meth has a sub-market in the city among men who have sex with men (Wendel et al., 2011), cocaine is the most prevalent stimulant contributing to overdose (Kline et al., 2023; Tuazon et al., 2023). Generally, qualitative research has found similar motivations for methamphetamine co-use with opioids (Ellis et al., 2018), but further research in markets where cocaine and methamphetamine are both available would be beneficial to further replicate motivations. Additionally, the eligibility criteria targeted individuals who are engaged in polysubstance use patterns conceptualized as high-risk for overdose but did not assess for substance use disorder or severity, so motivations may not extend to other subpopulations of persons who use drugs, particularly individuals who use drugs less frequently.

Conclusion

As the overdose crisis continues and researchers and clinicians work towards interventions targeting polysubstance use among persons who use drugs, there is an increasing need to consider motivations of co-use. Motivations of use provide important insight into possible mechanisms (e.g., emotional and physical pain) to target through interventions provided in harm reduction and treatment settings. Future research should continue to explore motivations of polysubstance use, and quantitative assessment of motivations would assist in correlating motives with specific patterns of use and other risk behaviors.

Biographies

Amanda M. Bunting is an addiction health researcher focused on patterns of polysubstance use and outcomes among vulnerable and underserved populations.

Adetayo Fawole is an assistant research scientist focusing on the evaluation and improvement of SUD treatment.

Brittany Griffin is a Senior Research Coordinator for the Bunting Research Lab. Brittany is particularly interested in addiction and substance use treatment research as well as public health policy.

Joshua D. Lee is a clinician–researcher focused on addiction pharmacotherapies in primary care and criminal justice populations.

Carrie B. Oser is an addiction health services scholar who leads interdisciplinary teams in conducting rigorous high-impact research to improve the lives of individuals with substance use disorders and promote health equity.

Jennifer McNeely is a clinician investigator whose research focuses on improving the identification and treatment of unhealthy substance use in general medical settings.