The proportion of drug overdose deaths in the US involving both fentanyl and stimulants increased more than 50-fold between 2010 and 2021. This surge represents a new phase in the country’s worsening opioid crisis, one characterised by concurrent fentanyl and stimulant use.
Since 1999, drug overdose deaths in the US have steadily risen, primarily due to the spread of prescription and illicit opioids like oxycodone, heroin and, more recently, fentanyl.
To better understand trends in fentanyl use, Chelsea Shover at the University of California, Los Angeles, and her colleagues collected data on overdose deaths between 2010 and 2021 using the US Centers for Disease Control and Prevention’s WONDER database. This database tracks all recorded fatalities in the country including where, when and how they occurred.
The researchers found that in 2021, almost a third of drug overdose deaths involved both fentanyl and a stimulant like cocaine or methamphetamine. That is a 50-fold increase from 2010 when less than 1 per cent of overdose deaths were attributed to the drug combination. They also found that by 2021, stimulants were the most common drugs involved in fentanyl-related overdose deaths in every US state. Previously, overdose deaths involving fentanyl usually occurred alongside prescription opioids, alcohol and heroin.
“Most of the US, especially the western US, is now dominated by [concurrent] meth and fentanyl use,” says Shover. “In the eastern US, it is more common to see cocaine co-involved with fentanyl.”
This signals a fourth wave in the US opioid epidemic, she says. The first wave began around 2000 with the rise of deaths from prescription opioids. The second occurred in 2010 with a shift towards heroin use and the third started a few years later as illicit supplies of fentanyl spread across the country. Now, the crisis has entered a new phase distinguished by simultaneous fentanyl and stimulant use.
Two factors probably underlie this change. First, people may be using stimulants to counteract the opioid’s sedative effect because sedation can leave them more vulnerable to robbery or assault, especially if they are experiencing homelessness, says Nora Volkow at the US National Institute on Drug Abuse in Maryland. Some users also report that the combination delays opioid withdrawal symptoms and increases euphoria.
The second factor is that drug dealers are deliberately adding illicit stimulants to the fentanyl they sell. This boosts their profits because fentanyl is cheaper than cocaine and methamphetamine, but also increases the risk of overdose as people without opioid tolerance are inadvertently consuming fentanyl, says Volkow. Plus, the combination is more lethal, especially since overdose-reversing medications, like Narcan, do not work against stimulants, she says.
“I think the implication [of these findings] in terms of preventing overdose is really working on improving options and access to treatment for stimulant use disorders as well as opioid use disorders,” says Shover. For instance, only 40 per cent of drug treatment facilities in the US in 2017 offered medication-assisted treatment – the gold standard for opioid use disorder.
“We have been prioritising the pipeline for medications for opioid use disorder, and now we are realising that we need to prioritise the medications for methamphetamine use disorder and cocaine use disorder too,” says Volkow. “Without doing that, we will not be able to effectively counteract the overdose deaths that we’re currently observing.”