Examining Increased Ritalin and Adderall Use Among Low-Income People Who Use Drugs: Mixed Methods Study.

Background: Popular discourse often frames prescription stimulants Ritalin and Adderall as drugs for teens and emerging adults with greater financial resources (eg, students or young professionals), while illicit stimulants such as crack or methamphetamine are often considered drugs for older adults with lower incomes. Crack and methamphetamine are also frequently used in combination with opioids to offset the sedating effects of adulterants such as fentanyl and xylazine in the unregulated drug supply. This combination of stimulant and opioid use creates additional overdose risks and may require new public health approaches. Our team posited that creating effective messages to protect against overdose in the context of stimulant use entailed first developing a better understanding of which stimulants people are using in combination with opioids. Objective: While conducting formative research to develop a new intervention, our team sought to examine prescription stimulant use among participants, including middle-aged, lower-income, and homeless people. This entailed first ascertaining the prevalence of Ritalin and Adderall use among participants, and then asking people why they used them. We also sought to implement a novel AI-assisted coding methodology and to write up the steps we took as a replicable model that other research teams could readily use to facilitate their own data analysis. Methods: We collected substance use screenings during 3 waves of data collection in 2025 (N=102 participants). In early 2026, we conducted 16 qualitative interviews with people who reported using Ritalin or Adderall. We then conducted mixed methods analyses to examine reported substance use, including the use of opioids and Ritalin or Adderall in combination, as well as potential relationships between using opioids with prescription stimulants and reporting a desire to stop using drugs. After conducting the interviews, we implemented a new hybrid methodology using AI tools to code interview transcripts and generate detailed reports accompanied by supporting quotes. Results: Participants described using Ritalin or Adderall to manage negative effects of increasingly powerful opioids, including oversedation and withdrawal symptoms. A subset of participants who reported using both Ritalin or Adderall and opioids were 3.5 times more likely to agree or strongly agree with the statement "I want to stop using drugs but I need help to do that" compared to those who did not report using these substances in combination (19/22, 86.4% vs 18/28, 64.3%; odds ratio 3.52, 95% CI 0.83-14.89; Conclusions: The use of prescription stimulants appears to be increasingly common among new populations of people who use opioids, including those who report very low incomes and even homelessness. Additional research is warranted to examine how this type of polysubstance use may require different types of prevention strategies.