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

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

In Pawtucket, Rhode Island, near a window advertising “free” cell phones, JR sat in an empty back stairwell and showed a reporter how he tries to avoid overdosing when he smokes crack.

(NPR is identifying him by his initials because he fears arrest for illegal drug use.)

Several hours had passed since his last dose, and the talkative middle-aged man’s hands were moving quickly. In one hand, he held a glass pipe. In the other, a crumb of cocaine the size of a lentil.

Or at least, JR hoped it was cocaine, pure cocaine—untainted by fentanyl, a powerful opioid linked to nearly 80% of all overdose deaths in Rhode Island in 2022.

He flicked his lighter to “test” his stash. If it smelled “like a sweet cigar,” he said, it meant his cocaine contained “fetty,” or fentanyl. He lifted the pipe to his lips and took a tentative drag. “No sweet,” he said, reassured.

But this “method” he has devised offers only false and dangerous assurance. Indeed, it is impossible to know with certainty whether a drug contains fentanyl by its taste or smell. And a mistake can be fatal.

“You might think you can smell fentanyl, taste it, see it … but that’s not a scientific test,” said Dr. Josiah “Jody” Rich, an addiction specialist and researcher who teaches at Brown University. “People are going to die today because they’re buying cocaine and they don’t know it’s got fentanyl in it.”

The mixing of stimulants like cocaine and methamphetamine with fentanyl — a synthetic opioid 50 times more potent than heroin — is driving what experts call the “fourth wave” of the opioid epidemic. This mix poses serious challenges to efforts to reduce overdoses because many stimulant users are unaware that they are at risk of ingesting opioids and therefore do not take precautions against overdoses.

The only way to know if cocaine or other stimulants contain fentanyl is to use drug screening tools like fentanyl test strips — a harm-reduction best practice now adopted by federal health officials to combat drug overdose deaths. Fentanyl test strips cost just $2 for a pack of two online, but many frontline organizations also distribute them for free.

    A test kit used to detect the powerful opioid fentanyl in a cocaine sample.

/ Lynn Arditi/The Public Radio

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Lynn Arditi/Public Radio

A test kit used to detect the powerful opioid fentanyl in a cocaine sample.

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

The third wave began when powerful synthetic opioids like fentanyl began appearing in the supply around 2015.

Experts are now seeing a fourth phase of the deadly epidemic. Nationally, illicit stimulants laced with fentanyl were the most common drugs found in fentanyl-related overdoses, according to a 2023 study published in the journal Science Addiction.

The stimulant in this deadly mixture 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 from drug overdoses is the combination of fentanyl and a stimulant,” said Joseph Friedman, a UCLA researcher and lead author of the study.

“Black and African-American people are disproportionately affected by this crisis, to a large extent, particularly in the Northeast.”

Factors causing polydrug overdoses

It’s unclear how much of the current trend in polydrug use is accidental or intentional. A recent study by Millenium Health found that most people who use fentanyl sometimes do so intentionally and sometimes unintentionally.

People often turn to stimulants to overcome rapid withdrawal from fentanyl, Friedman said. And the high-risk practice of using cocaine or methamphetamine with heroin, known as speedballing, has been around for decades.

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

But in Rhode Island, researchers say, many people still think they’re using pure cocaine or crack, a misconception that can be deadly.

Stimulant users unprepared for fentanyl’s ubiquity

“People who use stimulants, and not intentionally opioids, are not prepared to respond to 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 called Preventing Overdoses Involving Stimulants.

Researchers surveyed more than 260 people in Rhode Island and Massachusetts who use drugs, including some who manufacture and distribute stimulants like cocaine.

More than 60% of respondents in Rhode Island had purchased or used stimulants that they believed contained fentanyl.

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

People who do not use opioids regularly have a lower tolerance, putting them at higher risk of overdose.

Additionally, many of the people surveyed in the study also use drugs alone, so if they overdose, they may not be detected until it is too late.

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

/ Lynn Arditi/The Public Radio

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Lynn Arditi/Public Radio

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

Dubois was a single mother raising two black sons. The oldest son, Clifton, had struggled with substance abuse since he was 14, she said. Clifton had also been diagnosed with ADHD and a mood disorder.

In March 2020, Clifton had just enrolled in a rehabilitation program as the pandemic intensified, Dubois said.

Because of the confinement in rehab, Clifton was upset that he couldn’t visit his mother. “He told me, ‘If I can’t see my mother, I can’t get into treatment,’” Dubois recalled. “And I begged him” to continue treatment.

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

Dubois’s 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 off drugs.”

Clifton went to live with family friends, first in Atlanta and then in Woonsocket, a former industrial town that has the highest drug overdose death rate in Rhode Island.

In August 2020, Clifton overdosed but was revived. Clifton later said he had been snorting cocaine in a car with a friend, Dubois said.

Hospital records show he tested positive for fentanyl.

“He was really scared,” Dubois said. After the overdose, he tried to “get off the cocaine and the hard drugs,” she added. “But he was taking pills.”

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

The day before, Clifton had purchased counterfeit Adderall, according to the police report. What he didn’t know was that the pill contained fentanyl.

“He thought that by avoiding illicit drugs … and just taking pills, he would get better,” Dubois said. “I really believe Cliff thought he was taking something safe.”

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

/ Lynn Arditi/The Public Radio

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Lynn Arditi/Public Radio

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

The opioid epidemic is driving up death rates among older black Americans (ages 55 to 64) and, more recently, Latinos, according to a study recently published in American Journal of Psychiatry.

But it’s too simplistic to focus solely on whether fentanyl is present, said Joseph Friedman, a UC San Diego researcher and author of the study.

For years, hospitals have safely used medical-grade fentanyl to relieve surgical pain because its potency is strictly regulated.

“It’s not the concentration of fentanyl that’s dangerous,” he said. “It’s the fact that its potency fluctuates wildly on the illicit market.”

Studies of illicit drugs, he said, show that the concentration of fentanyl in illicit drugs can range from 1 to 70 percent.

“Imagine if you ordered a mixed drink at a bar and it had anywhere from one shot to 70 shots,” Friedman said, “and the only way to know if it was OK was to start drinking it… There would be a huge number of deaths from alcohol overdoses.”

Drug testing technology can provide a rough estimate of fentanyl concentration, he said, but getting an accurate measurement requires sending the drugs to a lab.

Fentanyl test strips provide an inexpensive way to prevent overdoses by detecting the presence of fentanyl, regardless of potency, in cocaine and other illicit drugs.

In Rhode Island, testing kits are available for free from harm reduction groups such as Project Weber/Renew.

But the test strips only work if people use them — and abstain from using the drugs if they test positive for fentanyl. And too few people who use stimulants do.

This story is from NPR’s health reporting partnership with Public radio And KFF Health News.

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