Stimulant users implicated in deadly ‘fourth wave’ of opioid epidemic

In Pawtucket, Rhode Island, JR sat in an empty back stairwell near a store that advertised “free” cell phones and showed a reporter how he tries to avoid an overdose when smoking crack.

(NPR is identifying him by his initials because he fears being arrested for using illegal drugs.)

It had been several hours since his last hit, and the talkative middle-aged man’s hands were moving quickly. In one hand he held a glass pipe. In the other, a lentil-sized crumb of cocaine.

Or at least JR hoped it was cocaine, pure cocaine – uncontaminated with fentanyl, a powerful opioid that has been linked to nearly 80% of all overdose deaths in Rhode Island in 2022.

He lit his lighter to “test” his stash. If it had a “cigar-like sweet smell,” he said, that meant his cocaine was laced with “fetty” or fentanyl. He put the pipe to his lips and took a cautious drag. “No sweetener,” he said reassuringly.

But the “method” he developed only offers a false – and dangerous – sense of security. It is actually impossible to determine for sure whether a drug contains fentanyl by taste or smell. And a mistake can be fatal.

“You may think you can smell, taste or see fentanyl … but that’s not a scientific test,” said Dr. Josiah “Jody” Rich, an addiction specialist and researcher who teaches at Brown University. “Today, people are going to die because they buy cocaine that they don’t know contains fentanyl.”

The mix of stimulants such as cocaine and methamphetamines with fentanyl – a synthetic opioid that is 50 times more potent than heroin – is driving what experts call the “fourth wave” of the opioid epidemic. The mix poses major challenges to efforts to reduce overdoses because many stimulant users are unaware they are at risk of taking opioids and therefore do not take precautions against overdose.

The only way to know if cocaine or other stimulants contain fentanyl is to use drug testing strips – a proven harm reduction method now adopted by federal health authorities to combat drug overdose deaths. Fentanyl testing strips cost as little as $2 for a pack of two online, but many organizations that are actively involved also give them out for free.

    A test kit for detecting the powerful opioid fentanyl in a cocaine sample.

/ Lynn Arditi/The Public’s Radio


Lynn Arditi/The Public’s Radio

A test kit for detecting the powerful opioid fentanyl in a cocaine sample.

In the United States, the first wave of the long-lasting and devastating opioid epidemic began with the abuse of prescription painkillers (early 2000s); the second wave was associated with an increase in heroin use starting around 2010.

The third wave began when powerful synthetic opioids such as fentanyl appeared on the market around 2015.

Now experts are observing a fourth phase of the deadly epidemic. According to a study published in the journal The 2023, illegal stimulants mixed with fentanyl were the drugs most commonly found in fentanyl-related overdoses. Seeks.

The stimulant in the deadly mix is ​​usually cocaine in the Northeast and methamphetamine in the West and much of the Midwest and South.

“The leading cause of death in the United States related to drug overdoses is the combination of fentanyl and a stimulant,” said Joseph Friedman, a researcher at UCLA and lead author of the study.

“Blacks and African Americans are being impacted by this crisis on a large and disproportionate scale, especially in the Northeast.”

Factors leading to multiple dosing

It’s not clear how much of the recent trend of mixing drugs is accidental or intentional. A recent study by Millenium Health found that most people who use fentanyl do so sometimes intentionally and sometimes unintentionally.

People often turn to stimulants to get through rapid withdrawal from fentanyl, Friedman said. And the risky practice of using cocaine or meth with heroin, known as speedballing, has been around for decades.

Other factors include manufacturers mixing the cheap synthetic opioid with a stimulant to stretch their supply or dealers mixing the bags.

But in Rhode Island, researchers say, many people still think they are using unadulterated cocaine or crack – a misconception that can be fatal.

Stimulant users are unprepared for the ubiquity of fentanyl

“People who take stimulants and not intentionally take opioids are unprepared for an opioid overdose … because they don’t perceive themselves as being at risk,” said Jaclyn White Hughto, an epidemiologist at Brown University and lead researcher on a new, unpublished study titled “Preventing Overdoses Involving Stimulants.”

The researchers interviewed more than 260 drug users in Rhode Island and Massachusetts, including some who manufacture and distribute stimulants such as cocaine.

More than 60 percent of the people they surveyed in Rhode Island had purchased or consumed stimulants that they later learned contained fentanyl.

In 2022, Rhode Island had the fourth-highest rate of cocaine overdose deaths after DC, Delaware and Vermont, according to the U.S. Centers for Disease Control and Prevention (CDC).

People who do not take opioids regularly have lower tolerance and therefore a higher risk of overdose.

And many of the people surveyed in the study also use drugs alone, so if an overdose occurs, it is possible that it will not be recognized until it is too late.

    Jennifer Dubois, a single mother whose 19-year-old son Clifton died of an overdose in 2020. The counterfeit Adderall pill he took contained the powerful opioid fentanyl.

/ Lynn Arditi/The Public’s Radio


Lynn Arditi/The Public’s Radio

Jennifer Dubois, a single mother whose 19-year-old son Clifton died of an overdose in 2020. The counterfeit Adderall pill he took contained the powerful opioid fentanyl.

Dubois was a single mother raising two black sons. The older son, Clifton, struggled with addiction since he was 14, she said. Clifton was also diagnosed with ADHD and a mood disorder.

In March 2020, when the pandemic began, Clifton had just checked into a rehabilitation program, Dubois said.

Because of the curfew in rehab, Clifton was upset that he couldn’t visit his mother. “He said, ‘If I can’t see my mother, I can’t do the treatment,'” Dubois recalled. “And I begged him to continue the treatment.”

But shortly after, Clifton left the rehab program. He showed up at her door. “And I just cried,” she said.

Dubois’ younger son lived at home. Dubois didn’t want Clifton to do drugs around his younger brother, so she gave Clifton an ultimatum: “If you want to stay home, you have to stay drug-free.”

Clifton lived with family friends, first in Atlanta and later in Woonsocket, an old mill town with the highest rate of drug overdose deaths in Rhode Island.

In August 2020, Clifton suffered an overdose but was resuscitated. Clifton later confessed to snorting cocaine in a car with a friend, Dubois said.

Hospital records show that his fentanyl test was positive.

“He was really scared,” Dubois said. After the overdose, he tried to “stay away from cocaine and hard drugs,” she said. “But he took pills.”

Eight months later, on April 17, 2021, Clifton was found unconscious in the bedroom of a family member’s home.

According to the police report, Clifton had purchased counterfeit Adderall the night before. What he didn’t know was that the Adderall pill was laced with fentanyl.

“He thought he would cope better if he stayed away from drugs and just took pills,” Dubois said. “I really think Cliff thought he was taking something safe.”

A memorial poster placed by friends of Jennifer Dubois in downtown Woonsocket, Rhode Island in 2023. The poster features her 19-year-old son, Clifton, who died of a drug overdose in 2020.

/ Lynn Arditi/The Public’s Radio


Lynn Arditi/The Public’s Radio

A memorial poster placed by friends of Jennifer Dubois in downtown Woonsocket, Rhode Island in 2023. The poster features her 19-year-old son, Clifton, who died of a drug overdose in 2020.

The opioid epidemic is driving up death rates among older African Americans (55-64 years) and, more recently, Latinx people, according to a recent study published in The American Journal of Psychiatry.

However, it is too simplistic to focus only on the question of whether fentanyl is present or not, says Joseph Friedman, a researcher at UC San Diego and author of the study.

Hospitals have been able to safely use medical fentanyl to relieve pain during operations for years because its strength is strictly regulated.

“The risk is not the strength of the fentanyl,” he said. “It’s the fact that the strength varies greatly on the illicit market.”

Studies on street drugs show that the fentanyl content of illegal drugs can vary between 1 and 70 percent, he said.

“Imagine you order a mixed drink in a bar that contains one to seventy shots,” Friedman said, “and you only know how to start drinking it… There would be a huge number of deaths from alcohol overdose.”

Drug testing technologies can provide a rough estimate of fentanyl concentration, he said, but to get an accurate reading, the drugs must be sent to a laboratory.

Fentanyl test strips provide a cost-effective way to prevent overdoses by detecting the presence of fentanyl in cocaine and other illicit drugs, regardless of strength.

In Rhode Island, the test kits are available free of charge from harm reduction groups such as Project Weber/Renew.

But the test strips only work if people use them – and then don’t use the drugs if they test positive for fentanyl. And not enough people who take stimulants do that.

This story comes from NPR’s health reporting partnership with Public radio And KFF health news.

Copyright: NPR