As the opioid crisis peaks, meth and cocaine deaths explode

WASHINGTON — Most states are keeping a close eye on opioid overdose deaths, but they may need to start focusing on cocaine and other stimulants as well.

It turns out that the same lethal drug that has been driving the nation's spiraling opioid epidemic is also causing a historic surge in overdose deaths among cocaine users.

That's according to a new analysis of death certificate data from the U.S. Centers for Disease Control and Prevention showing that fentanyl — a cheap synthetic opioid that is a hundred times more potent than morphine — and other opioids were involved in nearly three-fourths of all cocaine overdose deaths and an increasing number of methamphetamine deaths.

In a drug overdose epidemic that has killed more than 700,000 Americans since 1999, state and local officials have been primarily concentrating on opioids, which were involved in nearly 70% of overdose deaths in 2017.

The CDC's new analysis indicates that public health and law enforcement officials should be just as vigilant when it comes to cocaine, meth and other prescription and illicit drugs of abuse in their communities.

"Broader awareness of emerging drug threats and how they intersect with the opioid overdose crisis will help public health officials and the health care community better tailor their prevention and response efforts for all the substances and combinations of substances people are using in their community," said Christopher Jones, strategy director at the CDC's National Center for Injury Prevention and Control, in a phone interview with Stateline.

In a few places, that's already happening.

John Eadie, a coordinator with the National Emerging Threats Initiative administered by the Office of National Drug Control Policy, is working with communities in Ohio, Vermont and Virginia to create a model drug surveillance system that can be used to design appropriate interdiction, prevention and treatment programs. At least seven other states have signed up to do the same.

"One of the reasons we're pushing this type of data on stimulants and other drugs is so that communities can do the work they need to do and get ahead of the next drug crisis fast, rather than waiting a decade like we did with opioids," Eadie said.

Roughly 14,000 cocaine users and 10,000 meth users died in the United States in 2017, an increase of more than a third compared with 2016 and triple the number of deaths in 2012.

That puts both stimulants — a class of drugs that speeds up physiological and nervous system activity — on par with the opioid depressant heroin, which was involved in 15,000 overdose deaths in 2017, according to the CDC.

Three years into what epidemiologists are calling the third wave of the opioid epidemic — in which fentanyl has been involved in the vast majority of opioid overdose deaths — the lethal drug is now showing up in the bodies of nearly as many people who used cocaine and meth as those who used heroin.

Misuse of both stimulants has increased in recent years, surpassing nonmedical use of opioids, according to an annual survey by the U.S. Substance Abuse and Mental Health Services Administration.

In 2016, 2.4 million Americans said they recently had started using cocaine, methamphetamines or prescription stimulants, including Ritalin and Adderall. The total number of current users of illicit and prescription stimulants that year was 13.6 million.

But increased stimulants use is not enough to account for the recent surge in deaths, said Jack Killorin, public safety director for the Overdose Response Strategy, a public health and public safety collaboration of the High Intensity Drug Trafficking Area Program.

Whether drug dealers are intentionally lacing the illicit drug supply with fentanyl remains an open question.

In general, large seizures of cocaine and methamphetamines coming into the country typically do not contain fentanyl or other opioids, Killorin said.

But, he said, in the Atlanta area, street-level seizures of illicit cocaine and meth almost always do. For geopolitical reasons, seizures of both cocaine and meth — which are an indicator of overall supply — are at the highest level seen in years, according to the U.S. Drug Enforcement Administration, and prices are rock bottom.

Since overdose death reports are primarily based on autopsies, it is typically unclear whether the deceased used contaminated drugs, combined two drugs in one injection or used both stimulants and opioids sequentially to manage their highs.

Killorin and others speculate that an increasing number of drug users may be injecting a mixture of heroin and cocaine, a classic but deadly combination known as a speedball, according to the National Institutes of Health.

And meth users may be adding heroin to the mix to create an equally powerful but dangerous combination known as a goofball, according to the CDC. Some may be using stimulants and opioids at different times to manage their highs.

And yet another group may be transitioning from heroin to cocaine — ironically, in some cases, to avoid fentanyl.

In some places such as San Francisco, a subset of opioid users say they prefer fentanyl to heroin, because the cost is lower and the high is higher, though shorter.

But surveys of opioid users by researchers at Brown University and the University of California, San Francisco indicate that most users consider fentanyl an undesirable contaminant and try to avoid it. Most cocaine users feel the same, addiction experts say.

In Baltimore, addiction researcher and treatment practitioner Yngvild Olsen, medical director of the Institutes for Behavior Resources and American Society of Addiction Medicine board member, said she’s seen a recent increase in people who previously had been treated for opioid addiction and returned for help with a cocaine problem.

"When I talk to them, virtually everyone says, 'I don't want to go anywhere near fentanyl. I don't look for it, I don't use it, I use cocaine. I need the upper, and I don't want anything to do with fentanyl.'"

Hardest hit in the recent stimulant overdose death scourge were Midwestern, Northeastern and Southern states where both meth and cocaine use were on the rise, according to the CDC.

The District of Columbia had the highest death rate involving cocaine, at 18 per 100,000 residents, followed by Ohio at 14 per 100,000.

West Virginia had the highest death rate involving meth at 14 per 100,000, followed by Alaska at 9 per 100,000.

Nationwide, the rate of cocaine deaths rose in 15 states, with the steepest spikes in Wisconsin (85%) and Maryland (72%). Meth overdose deaths rose in 17 states, with the steepest increases in Ohio (130%) and West Virginia (94%), the analysis showed.

More than twice as many men as women died of stimulant overdoses in 2017, and black people experienced both the highest death rate and the biggest increase in deaths from cocaine. Native Americans and Alaska Natives experienced the highest death rate from meth and the biggest rate increase, according to the CDC.

Nationwide, provisional 2018 data from the CDC indicates stimulant overdoses were continuing to rise last year as overall drug deaths leveled.

Stateline is an initiative of The Pew Charitable Trusts.