Background: Co-use of heroin kerack with methamphetamine (MA) is a new epidemic health concern among Iranian female drug users. Yet, little is known about this issue because of stigma. Objectives: The current study aimed to investigate the reasons associated with initial and continued co-use of heroin kerack with MA among two groups of regular and recreational female co-users, their motivations associated with treatment entry and to compare their general characteristics at a drop in center (DIC) in Tehran. Materials and Methods: 82 clients were randomly recruited. A researcher-designed questionnaire was used to collect data. Data was analyzed by performing descriptive statistics, the Chi-square test and t-test. Results: The mean age of the participants were 31 (SD = 8) years. Reducing negative affect (55%), addicted family and social networks (50%), curiosity (48%), and the lack of knowledge on addictive effects of co-use of heroin kerack with MA (32%) were the most frequently reported reasons at initiation. Drug dependence (71%) and drug availability (56%) were reasons of continued co-use. Restoring health (61%), fear from becoming MA abuser only (33%), and fear from making a transition from heroin kerack and MA smoking to injection (15%) were important motivations for treatment entry. Regular co-users were more likely to be single (41.7% vs. 14.7%, P < 0.001), jobless (45.8% vs. 38.2, P < 0.05), homemaker (50% vs. 35.3%, P < 0.01), recently incarcerated (16.7% vs. 11.7%, P < 0.01), and were less likely to be enrolled in opioid replacement programs (33.5% vs. 41%, P < 0.01). Regular co-users were younger (30.6 vs. 32.1 years, P < 0.05), less educated (9.6 vs. 10.8 years, P < 0.05) and had a longer duration of drug dependence (9.6 vs. 8 years, P < 0.05). Conclusions: Reasons associated with initial and continued co-use of heroin kerack with MA, factors associated with treatment entry and the differences between regular and recreational co-users should be specifically considered in designing and tailoring drug use treatment programs for this group.

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