Phenomenology of Methamphetamine Abuse among Patients undergoing Methadone Maintenance Treatment in Iran: A Qualitative Study Seyed Ramin Radfar Sarah J Cousin Alireza Noroozi Sara Jafari Richard A Rawson

 Conflict of Interest: None  IRB Approval:  This study is approved by both the University of California at Los Angeles (UCLA) Human Subjects’ committee and the Tehran University of Medical Science Ethics Committee and is part of an IAS/NIDA-funded fellowship at UCLA Integrated Substance Abuse Programs.

 Qualitative study  focus group discussion (FGD)  Isfahan, Iran, within varying settings of private, governmental, drop in centers and women friendly facilities. FGDs conducted in a private room, in the clinic and nobody except the research team and participants had access to the room during FGD. In each center, patients were informed by flyers and volunteers who identified eligible invited for one session FGD. Same-sex interviewer conducted FGDs and a gift voucher equal to 8 US$ delivered to each participant before the starting questions, refuse for participation in the FGD had no effect on the amount of incentive or process of the treatment. Eligibility criteria included: · Patients with at least six months history of being enrolled in opioid substitution therapy at the time of interview · Aged 18 years old and older · Ability to understand the concept of informed consent and willingness to sign a consent form. All the sessions recorded with the consent of the participants and participants were free to end participation at any time, but none used this option. All sessions were transcribed by a trained transcriptionist and re-verified with recorded voices. Analysis of the FGDs: thematic approach by ATLAS.ti version

 Totally 7 FGDs (13 Female, 32 Male) conducted between December 2013 and February 2014, 2 of FGDs conducted with female participants in women friendly facilities and 5 other FGDS conducted in drop in center, governmental and private outpatient drug abuse treatment clinics with 2, 2, and 1 FGDs respectively in each center.

Extracted Factors  Positive attitude toward methamphetamine  Male Participant: “Everybody knows that methadone and methamphetamine are very match with each other because both have negative urine test (for morphine)”

 Methadone cons:  Male participant: “After a few months of MMT, I was so unable to have sex with my wife that she rebuked me as I was less than a rooster!”  Male Participant:” My wife told me that I am sure you are with someone else because you are not interested to have sex with me”  Female participant: “In the first months of treatment I was unable to do any of my home works and care of my children”

 Methamphetamine pros:  Female participant: “When I am really in conflict with my husband and kids and poverty, this is only methamphetamine that can help me tolerate this situation”

 Methamphetamine cons:  Male participant: “When I was on methadone, I was so busy with my works that I had not time even to come and take my weekly dose, but after a few months of methamphetamine use I am not only jobless but also my wife is now living separated and we are in the process of divorce because I was very suspicious to her and she couldn’t tolerate”  Female participant: “I spent a whole night for cleaning the sink and cabinets in my kitchen and I was continuing until my family took me and gave me to psychiatry hospital”

+uid [HELP TO REDUCE METHADONE DOSE Increase in Energy] Increase in Libido Increase in mood and tolerance Increased Self Esteem Physical side effects Loss of energy Decrease in Libido Being Tired of Methadone Use Reduce in Living costs Reduce in family conflict and feud Methamphetamine use has no side effect REDUCING CRAVING FOR OTHER DRUGS AND OPIUMS Positive Attitude Methadone Pros Methamphetamin e Pros Methadone Side effects

Positive attitude to Methamphetamine PROSPROS CONSCONS TIME Methadone in Normal situation Methamphetamine Peer Pressure to use Methamphetamine Best time for Intervention What is happening in this system? Methadone with Methampheta mine

Recommendations:  Education the patients and their families regarding natural process of the MMT  Education the patients and their families regarding the side effects and also NATURAL PROCESS of the Methamphetamine  Urine Testing  Recruiting Ex-Meth user in the process of the treatment