• Trapped by myths, peer pressure and psychological dependence
• Initiation is largely socially mediated, driven by peer influence, curiosity, emotional distress
• Continued use is psychologically reinforced and sustained by physiological craving

Methamphetamine (ice) use in Sri Lanka is sustained by a complex interplay of social exposure, psychological vulnerability, and cognitive distortions regarding perceived benefits. Initiation is largely socially, driven by peer influence, curiosity, and emotional distress. Continued use is psychologically reinforced by perceived functional enhancement, including improved energy, productivity, and sexual performance, despite progressive psychological and physical harm. A transition from initial euphoria to paranoia, low mood, and functional decline is commonly described. Persistent cognitive distortions, including beliefs in self-medication and functional benefits, contribute to ongoing use. Barriers to abstinence (psychological, social, environmental, and behavioural factors preventing or delaying cessation) included craving, motivational ambivalence, social influences such as entrapment, and easy availability. Misconceptions regarding treatment, including the use of other substances, are also evident. Methamphetamine use is driven not only by addiction but also by powerful misconceptions that the drug improves productivity, confidence, sexual performance, and emotional well-being. These beliefs, together with peer influence and psychological distress, make quitting particularly difficult.

These findings were made in an original article on the "Lived experiences of methamphetamine users in Sri Lanka: A qualitative study on initiation, continuation, and barriers to abstinence" which was authored by J Galhenage, M Dayabandara and R Hanwella, A Isuru, and K Abayasinghe, and published in the Ceylon Medical Journal. 

The global burden of methamphetamine use has risen markedly over the past decade, with mortality and morbidity nearly doubling (M.P. Paulus and J.L. Stewart's "Methamphetamine use disorder: The next addiction crisis"). Methamphetamine use disorder is increasingly recognised as a major global public health concern. In Sri Lanka, Police statistics indicate a steady rise in methamphetamine use (the National Dangerous Drugs Control Board's "Survey on methamphetamine [ice] use-related prevalences in Sri Lanka 2020"). Multiple factors contribute to initiation and maintenance, with substances such as tobacco, alcohol, and cannabis acting as common gateway drugs (a Thai study). Methamphetamine intoxication is strongly associated with aggressive behaviour, often manifesting as violence within households. By 2020, methamphetamine users in Sri Lanka reportedly spent Rs 1,000-10,000 per day, causing financial hardship, and arrests increased from six in 2017 to 2,073 in 2019. Understanding methamphetamine use patterns has implications for psychiatry, general medicine, law enforcement, rehabilitation, and public awareness.

Methodology

Galhenage et al. study was a qualitative, descriptive one informed by an interpretivist perspective (explored participants' personal experiences and perspectives). The study was conducted at the Substance Use Disorder Management Clinic, the Outpatient Psychiatry Clinic, the general medical wards, and the Professorial Psychiatry Unit of the NHSL, Colombo. These services manage individuals presenting with substance-related disorders from diverse urban and suburban communities. Purposive sampling was used to recruit participants with a direct lived experience of methamphetamine use. A total of 37 participants were included. Eligible participants were individuals aged above 15 years with a history of methamphetamine use who were clinically stable and able to provide informed consent. Participants with severe cognitive impairment or acute intoxication that interfered with meaningful participation were excluded. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for methamphetamine use disorder were assessed by trained clinicians attached to the psychiatry service as part of routine clinical evaluation. Data were collected through in-depth, semi-structured interviews using a pre-tested interview guide. Interviews were conducted in Sinhala in a private setting and lasted approximately 30-60 minutes. Field notes documenting non-verbal behaviour, emotional responses, and contextual observations were maintained during and immediately after the interviews. Interviews were conducted by medical practitioners with postgraduate training in psychiatry and experience in substance-use care. Interviewers used non-judgemental prompts, encouraged participant-led narration, and engaged in reflexive discussions throughout the analytic process.

Results

Participant characteristics

A total of 37 participants were interviewed, of whom, 31/83.8 per cent were male. Participants ranged in age from 15 to 56 years (mean 30.16 years plus/minus 9.66 years). Most were employed (31/83.8%) and had received education up to Grade 11 (25/67.6%). A total of 13/35.1% had been referred through court or the Police services. A total of 30/81% reported daily or weekly methamphetamine use, and 23/62.2% met the DSM-5 criteria for methamphetamine use disorder. Concurrent heroin dependence was present in 15/40.5%, while 27/79.4% reported contemplating cessation. Participants commonly used the street term ice when referring to methamphetamine.

Three overarching themes emerged: socially mediated initiation; perceived functional enhancement and psychological reinforcement; and entrapment, harm, and barriers to abstinence.

Socially mediated initiation

Methamphetamine initiation was commonly embedded within social and relational contexts. Participants described first exposure occurring at social gatherings, funeral houses, workplaces, peer gatherings, and in the context of intimate relationships. Curiosity, experimentation, social acceptance, and emotional vulnerability emerged as prominent initiating influences.

Many described peers facilitating initiation by introducing methamphetamine as a novel or socially desirable experience, often providing it free of charge. “My friend showed me how to inhale and even gave me some free to try” - a 32-year-old male sales representative.

Initiation also occurred within intimate relationships, where methamphetamine use was introduced by partners and became normalised within relational interactions. “My partner first offered me 'ice', heating it on glass” - a 29-year-old female commercial sex worker.

Several described emotional distress, loneliness, separation, or hopelessness as precipitating factors that increased vulnerability to experimentation. “After my wife left me, I was depressed and suicidal, so, I tried this to overcome my sadness” - a 35-year-old male bricklayer. 

Early experiences were frequently described as pleasurable and energising, with participants reporting increased alertness, confidence, motivation, and sexual desire. These experiences were often interpreted as beneficial and reinforced continued experimentation. “After taking 'ice' I feel like a lion – I can finish tasks swiftly” - a 32-year-old male sales representative.

However, some simultaneously described early adverse psychological experiences including suspiciousness, paranoia, irritability, low mood, and hallucinations. “Only when I use 'ice' do I feel that people are spying on me, even my family” - an 18-year-old unemployed male.

These accounts suggest that initiation was shaped by a complex interaction between social exposure, emotional distress, and early perceived functional benefits despite emerging psychological disturbance.

Perceived functional enhancement and psychological reinforcement

The continuation of methamphetamine use was strongly sustained by the participants’ perceptions that it improved physical endurance, concentration, emotional coping, occupational performance, and sexual functioning.

Several viewed methamphetamine as essential for sustaining physically demanding work and remaining productive during extended periods of labour. “I use 'ice' to stay awake at night to collect iron pieces for money” - a 42-year-old male manual labourer. 

Others described using methamphetamine to cope with emotional pain, loneliness, and psychological distress. “I was so sad and helpless. To get rid of those feelings, I used 'ice'” - a 35-year-old male bricklayer who was separated.

Participants expressed cravings and withdrawal discomfort as reinforcing repeated use. “I continued using because of craving and experienced bone pain when I stopped” - a 20-year-old male helper. 

Perceived sexual enhancement also emerged repeatedly as a powerful reinforcing belief. “My partner and I consume ice to enhance sexual activity for about one and a half hours” - a 29-year-old female commercial sex worker. 

Despite these initially perceived benefits, participants described progressive psychological deterioration over time, including irritability, suspiciousness, low mood, hallucinations, cognitive difficulties, and emotional instability. “After a few days of stopping 'ice', I became easily irritable and felt mistreated by the family” - a 19-year-old male van driver.

Some also described memory impairment and reduced occupational functioning. “I had short-term memory loss and poor concentration, causing problems at work and the loss of business” - a 21-year-old male salesman. 

These narratives reflect a shift from perceived functional enhancement to psychological dependence and worsening psychosocial impairment.

Entrapment, harm, and barriers to abstinence

Participants described methamphetamine use as increasingly difficult to control, sustained by psychological dependence, social pressures, easy availability, and persistent beliefs regarding its functional benefits.

Repeated failed attempts at cessation were common, often characterised by postponement and ambivalence. “I thought of stopping, but, whenever I tried, I told myself that I would just use today and stop tomorrow” - a 29-year-old mother of one. 

Interpersonal coercion and peer pressure also contributed to continued use. “My husband pressured me to use 'ice' and have sex with his friend, making it hard to stop” - a 30-year-old mother of two. 

Several believed that methamphetamine was necessary for concentration, planning, emotional regulation, or relief from psychiatric symptoms. “I couldn’t stop because I needed 'ice' to plan strategies and perform multi-tasking mentally” - a 27-year-old male library assistant.

Participants described substantial social consequences including family conflict, stigma, financial decline, occupational disruption, and social isolation. “I experienced economic decline, broken family ties, and detachment from my wife and children” - a 35-year-old unemployed male. 

Participants identified medications, psychotherapy, rehabilitation, social support, and lifestyle changes as potentially effective interventions. However, misconceptions regarding treatment persisted, including substituting heroin to reduce methamphetamine-related distress. “I tried using heroin to manage 'ice' addiction, but, it didn't work” - a 49-year-old male electrician. 

These findings suggest that barriers to abstinence were sustained not only by dependence but also by deeply embedded cognitive and social beliefs regarding methamphetamine’s perceived utility.

Summary of the thematic findings

The thematic analysis suggests a progressive trajectory of methamphetamine use in which socially mediated experimentation evolves into perceived functional dependence and psychological reinforcement, before culminating in social, emotional, and behavioural entrapment that complicates abstinence. Across participants’ accounts, continued use was sustained not only by physiological craving but also by persistent beliefs regarding enhanced productivity, emotional relief, confidence, and social functioning, despite mounting psychological distress and psychosocial deterioration.

Discussion

Methamphetamine use is sustained through a dynamic interaction between social exposure, emotional distress, perceived functional enhancement, and progressively reinforcing psychological dependence. Methamphetamine use is not solely maintained by physiological craving, but also by culturally shaped misconceptions regarding productivity, emotional resilience, confidence, concentration, and sexual performance.

Initiation commonly occurred within socially mediated environments including peer gatherings, workplaces, intimate relationships, and funeral settings. Curiosity, experimentation, emotional vulnerability, and social acceptance are prominent initiating influences. Peer influence, novelty seeking, occupational pressure, and psychosocial distress are identified as common drivers of methamphetamine initiation (a Chinese study). The prominence of funeral houses as sites of first exposure likely reflects distinctive Sri Lankan sociocultural practices, where extended overnight communal gatherings may create opportunities for exposure and social reinforcement (J. Hays's "Funerals and ideas about deaths in Sri Lanka").

Participants reported methamphetamine as enhancing confidence, alertness, concentration, endurance, and occupational functioning. Methamphetamine is often perceived as a functional stimulant that improves productivity and the coping capacity (Thai and Iranian studies). However, these perceived benefits appeared transient and frequently evolved into paranoia, suspiciousness, hallucinations, irritability, cognitive impairment, emotional instability, and social deterioration (T.A. Wearne and J.L. Cornish's "A comparison of methamphetamine-induced psychosis and schizophrenia: A review of positive, negative, and cognitive symptomatology"). This progression suggests that participants often misinterpreted short-term stimulant effects as sustainable functional improvement, reinforcing continued use despite mounting harm.

Emotional distress emerged as an important sustaining factor. Several described using methamphetamine to cope with loneliness, a relationship breakdown, hopelessness, and psychological discomfort. This aligns with self-medication models of substance use (E.J. Khantzian's "The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence") and highlights the need to recognise untreated emotional distress as a major driver of continued stimulant use (D.H. Lende, T. Leonard, C.E. Sterk and K. Elifson's "Functional methamphetamine use: The insider’s perspective"). Such findings are particularly relevant in Sri Lanka, where psychological distress often remains under-recognised and addiction services remain predominantly focused on acute crisis management rather than sustained longitudinal psychosocial rehabilitation.

A key finding was the persistence of cognitive and social misconceptions regarding methamphetamine’s perceived benefits. Participants frequently believed that methamphetamine improved occupational efficiency, sexual functioning, emotional control, and concentration, despite simultaneously reporting significant interpersonal conflict, financial deterioration, stigma, and occupational decline (an Iranian study, the National Institute on Drug Abuse' Methamphetamine-drug facts, and American studies). These beliefs appear to function as powerful cognitive reinforcers that sustain use beyond physiological dependence. In low- and middle-income (LMI) settings, stimulant use becomes normalised as a functional coping strategy despite harmful consequences Participants also described substantial barriers to abstinence including craving, easy availability, peer pressure, social coercion, low motivation, and the repeated postponement of cessation attempts. These barriers were often reinforced by beliefs that methamphetamine was necessary for emotional regulation or productive functioning. This suggests that treatment approaches focused solely on detoxification are unlikely to achieve sustained recovery unless these underlying beliefs are actively addressed through structured psychosocial interventions. The findings have important implications for Sri Lanka’s evolving response to stimulant use. Current public health messaging often emphasises legal consequences and general anti-drug warnings, participants’ accounts suggest that prevention strategies should directly challenge specific misconceptions regarding productivity, confidence, sexual enhancement, and emotional coping. Early screening for stimulant-related problems should be strengthened within psychiatric, primary care, emergency, prison, and community health settings, particularly among young adults presenting with psychotic symptoms, occupational decline, emotional distress, or risky sexual behaviours.

The findings also highlight service delivery gaps. Participants identified psychotherapy, rehabilitation, family support, and medication as potentially helpful interventions. Although no medication has demonstrated definitive efficacy for sustaining methamphetamine abstinence, emerging pharmacological approaches show preliminary promise. Strengthening access to evidence-based psychosocial interventions – including motivational interviewing, cognitive behavioural therapy, contingency management, relapse prevention strategies, and family-focused rehabilitation – may improve outcomes (a Thai study). Misconceptions regarding treatment remain common, including attempts to substitute heroin to reduce methamphetamine-related distress. Community-based rehabilitation services and stigma reduction initiatives are particularly important in facilitating long-term reintegration and recovery.

Methamphetamine use is sustained through an interaction of social exposure, emotional vulnerability, perceived functional enhancement, and entrenched cognitive misconceptions. Addressing these drivers will require culturally responsive prevention strategies, early psychological intervention, family engagement, evidence-based psychosocial treatment, and strengthened community rehabilitation systems within Sri Lanka’s addiction treatment framework.