The significant numbers of new HIV infections among men who have sex with men (MSM) have brought renewed attention to risk practices related to the use of speed among MSM. However, the primary focus on sexual risk has produced gaps in understanding the role of injection risk. In this critical review, we identify tenacious biases in earlier research and present epidemiological indicators of speed use among MSM. We outline four major areas for future research: (1) transitions into injection, (2) situational injection groups, (3) speed injection practices, and (4) risk reduction interventions. Aiming to inform risk reduction interventions for MSM, we describe how an ethnographic epidemiology might reconceptualize the interaction of sexual and drug risk. Detailing a venue-based research approach, we propose ways to study how MSM use speed to “script” both sexual and injection risk behaviors in the context of social hierarchies and commercial settings.