The spike of drug overdose deaths this year and last year has many drug abuse and addiction researchers, doctors and health officials worried about a growing trend among overdose victims that appears to indicate a new and different wave of the opioid epidemic.
While the loneliness and the challenges of the coronavirus pandemic appear to have driven drug use, many experts say the latest overdose wave is driven in part by the use of fentanyl with other drugs.
Overdose deaths hit new heights in the U.S. — over 100,000 dead this year, according to the Centers for Disease Control and Prevention — but experts say it’s part of a fourth wave of the overdose epidemic, in which a growing number of drug users die with multiple substances in their systems.
Behind that 100,000 figure, they said, is an ongoing surge in the number of cocaine, methamphetamine and other drug deaths that are connected to the simultaneous use of fentanyl.
“Probably more than half of the cases involve fentanyl mixed with another drug,” said Dr. Robert Anderson, the chief of mortality statistics at the CDC’s National Center for Health Statistics.
The co-use of fentanyl and other drugs distinguishes this wave from the ones that came before it, which were characterized by the growing use of prescription pain medications and then the rise of heroin and fentanyl individually.
"I actually don’t refer to it as an opioid epidemic,” said Dr. James Berry, the director of addiction services and chair of the behavioral medicine department at West Virginia University. “I refer to it as an addiction epidemic, because the substance varies, and there’s typically more than one substance being used.”
Although the trend has been identified, it’s not yet definitive what is causing it: Are drug users knowingly using fentanyl and other drugs, or does fentanyl enter the larger drug supply via dealers and distributors?
“It really could be happening at any point and multiple points along the drug supply chain,” said Kelly Dougherty, Vermont’s deputy health commissioner for alcohol and drug abuse programs. “Some people want to use fentanyl, despite the dangers, and other people are using it without knowing — it’s scary. People are cutting it in, and it basically makes it more deadly.”
While Vermont is working to make fentanyl test strips more accessible so users can check whether their drugs are contaminated, Dougherty said users should assume more often than not that any illicit drugs they buy may contain fentanyl.
The Biden administration announced this year that state and local governments can use federal funds to purchase fentanyl test strips in hope of curbing the spike in overdose deaths.
But many experts believe fentanyl is entering the greater drug supply at the distributor level. Distributors or dealers appear to be either cutting other drugs with fentanyl, as it is particularly cheap and provides a strong high, or contaminating their other drugs by accident by using unclean work surfaces, gloves and tools.
“There are instances where patients will be actually co-using both cocaine and fentanyl purposely,” said Berry, who cited some of his interactions with patients, “but a lot of it is just the fact that almost everything you could think of is cut with fentanyl on the streets nowadays.”
Besides anecdotes and assumptions, however, there is little firm data on why a growing number of overdose victims have multiple drugs in their systems when they die.
Dr. Daniel Ciccarone, an addiction and drug researcher at the University of California, San Francisco, said it remains unclear whether most overdoses are caused by intentional co-use of fentanyl with other drugs or whether contamination or alteration is happening at the dealer level. He said the real reason remains in a “black box” that needs to be unpacked with further research.
“I think the contamination hypothesis is overblown and it’s fear-based,” said Ciccarone, who has published about the fourth wave of overdoses and is working on a study about the reasons behind the latest trend. “There’s evidence from around the country — a couple papers that have been published, but also data from my research in places like West Virginia — that show that the combination use of methamphetamine or a powerful stimulant with a powerful opioid is a popular combination now.
“This is a big, growing phenomenon,” he added. “It’s one we shouldn’t ignore.”
Unfortunately, the problem has multiple heads.
Brendan Saloner, a Johns Hopkins School of Public Health professor who studies drug addiction and treatment, said fentanyl is beginning to move across the country and affecting communities that haven’t had to address the opioid epidemic in the past.
“It seems like what’s happening is that a lot of the overdose risk has just shifted to parts of the country that didn’t really have as much susceptibility before, so I think it’s taking a lot of people by surprise right now,” Saloner said. “Certainly some places, especially west of the Mississippi, it looks like it’s gotten really bad in a hurry.”
Beyond that, Saloner said, state and local governments need to work to build back addiction treatment and outreach systems that were left unattended during the pandemic. Addiction services, he said, should be the main focus of efforts right now.
He said the U.S. also needs to expand whom it provides with those services and work in areas that aren’t given resources to address the opioid epidemic.
“Settings like hospital emergency departments, where most people can’t get treated, or jails and prisons need greater attention,” he said. “There are a lot of crisis systems that just don’t help people very well right now.”