What does it mean to you when you say “it works”? User perspectives on stimulant agonist therapy (STAT)

Since the 2016 declaration of the overdose crisis in British Columbia (BC), over 16,000 people have died from using the toxic drug supply (BC Coroners Service, 2025). Although the driver of this public health crisis is illicit fentanyl, users of drugs beyond opioids are impacted. For instance, after fentanyl, the second and third-most detected substances within posthumous toxicology testing are cocaine and methamphetamine. These fatality cases are likely either users of both illicit opioids and stimulants who succumbed to an unpredictable dose of the former substance, or opioid-naive stimulant users unintentionally exposed to fentanyl cross-contamination. In either case, at least half of those dying from unregulated drugs are using stimulants. Because of this, in order to reduce exposure to the toxic drug supply, pharmacological alternatives to stimulants should be explored. One potential intervention is stimulant agonist therapy (STAT): pharmaceutical stimulants commonly prescribed to treat attention deficit hyperactivity disorder (ADHD) used to replace or control the use of illicit stimulants. STAT options were included in provincial prescribed safer supply (PSS) guidelines first released in 2020. Presently, less than 10% of PSS patients receive stimulants. Prescribers have decried a lack of evidence, citing meta-reviews for randomized clinical trials (RCTs) for stimulant replacement therapy (SRT) that show limited efficacy. However, not only do these meta-reviews include RCTs for a number of non-stimulant medications, but are the tested outcomes of these RCTs congruent with lived successes of STAT patients? To explore this question, ten STAT patients throughout BC were recruited between October 2021 and February 2022 to participate in remote semi-structured qualitative interviews that focused on what it meant to them for STAT "to work". For most participants, using STAT in preferred formulation, dosage, and route of administration resulted in significant increases in quality of life, including functionality, mental wellness, connection, and paid employment, as well as reduced illicit stimulant use. Notably, despite these changes, almost none would be successful RCT participants, as even occasional illicit stimulant use would disqualify them according to the primary measure of evaluation: drug cessation within the study period. This research reveals patterns and strategies of successful STAT use that contradict the design of SRT RCTs and challenge their relevancy as evidence against STAT, as well as interrogates the methodological appropriateness of RCTs to evaluate the effectiveness of STAT at all.