"Motives for using methamphetamine with heroin/fentanyl can be conceptualized as forming three thematic categories: ‘intrinsic use’, representing the inherent pleasure of the combination or self-medication of particular conditions; ‘opioid assisting use’ in which methamphetamine helped manage existing heroin/fentanyl use and ‘reluctant or indifferent use’. All 30 individuals had some experience using methamphetamine, whether separately or combined with heroin.

"We heard about and witnessed several ways that people used the two drugs, including simultaneous or alternating injections along a temporal spectrum. Daily order of dosing was another important and varied aspect of goofball use, with participants’ strategies dependent upon time of day, activity level, social situations and other factors. Most participants prioritized heroin over methamphetamine due to managing both opioid withdrawal and limited financial resources. Participants generally used the term ‘heroin’ to describe heroin, heroin adulterated with fentanyls and fentanyls without heroin; this language is reproduced in this paper to incorporate both drugs. Participants used the term ‘speedball’ to indicate co-injection of heroin and methamphetamine simultaneously, and generally did not use this term to refer to use separated in either time or mode of use (snorting, smoking). Ratios of heroin to methamphetamine within a speedball varied significantly among participants based on opioid tolerance, social situations and personal preference.

"The co-use of heroin and methamphetamine, known locally as a ‘speedball’, a term used elsewhere to describe a cocktail of heroin and cocaine, gained popularity among our sample within the last several years, and was virtually unknown before approximately 2015. This was despite the earlier presence of domestically produced ‘shake and bake’Footnote1 methamphetamine in the local drug culture, albeit recently less widely available than the newer ice. Heroin was also a latecomer to the area, with evidence suggesting that the local market developed from 2012 onwards [35]. Among participants where the order of drug progression was clear, all had initiated their opioid use with prescription opioid pills, but had transitioned to heroin after the pills became prohibitively expensive and more difficult to obtain."


Ondocsin, J., Holm, N., Mars, S.G. et al. The motives and methods of methamphetamine and ‘heroin’ co-use in West Virginia. Harm Reduct J 20, 88 (2023). doi.org/10.1186/s12954-023-00816-8