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The overdose epidemic has been split into three “waves,” characterized by prescription opioids, heroin and fentanyl. A new, “fourth wave” of the overdose epidemic was identified in a new report from Millennium Health.
Stimulants, including methamphetamine and/or cocaine, have emerged as a key driver of overdose-related deaths, the report demonstrated. Stimulants were involved in less than 1% of fentanyl-related overdose deaths in 2010. By 2021, that number grew to almost one-third.
San Diego, California-based Millennium Health is one of the largest urine drug testing laboratories in the U.S. and monitors drug use trends.
Millennium’s report analyzed urine drug test data to determine which substances were most commonly used in conjunction with fentanyl. Urine test surveillance is beneficial to provide insight into drug use patterns because the data is updated rapidly and significantly correlates with national, state and county-level overdose mortality patterns.
More than 90% of studied urine specimens tested positive for another drug as well as fentanyl, demonstrating widespread polysubstance use. Almost 60% of the specimens tested positive for between two and four additional drugs.
Polysubstance use is especially dangerous because people may not know that they are ingesting other substances along with their drug of choice.
“It is tough to organize a battle if we don’t know exactly what we are fighting against,” Eric Dawson, vice president of clinical affairs at Millennium Health, told Addiction Treatment Business in an email. “Clinicians need to know everything a patient is taking to make the most informed patient care decisions.”
Not knowing what drugs a patient has taken can have potentially deadly consequences, Dawson explained.
For example, if a patient is using cocaine that, unbeknownst to them, is contaminated with fentanyl, a clinician who is relying only on the information provided to them by the patient is left “partially blindfolded.”
“The clinician may not anticipate opioid withdrawal as the patient discontinues use nor warn the patient against the dangers of fentanyl and provide naloxone as part of their care, leaving the patient at continued risk of fentanyl overdose should they return to “cocaine” use,” Dawson said.
Among the drugs used in combination with fentanyl, methamphetamine was the most common, with 60% of specimens testing positive.
“National, regional, and state-level UDT data all suggest that people who use fentanyl are now, intentionally or unintentionally, much more likely to also use methamphetamine and cocaine,” the study’s authors said.
Following methamphetamine were cannabis, cocaine, acetylfentanyl, parafluorofentanyl, heroin, prescription benzodiazepines and xylazine.
The use of methamphetamine alongside fentanyl has sharply increased over time; detection of the drug with fentanyl has increased by 875% since 2015.
While methamphetamine has become a more popular companion to fentanyl, prescription opioids and heroin have become less so. Tests that are positive for both fentanyl and prescription opioids reached a “historic low” in 2023, down 89% since 2013.
The shift from heroin and prescription opioids to stimulants can be attributed to several causes, Dawson said.
Methamphetamine and cocaine both heighten the euphoria of fentanyl. Methamphetamine can also counter fentanyl’s significant depressant effects, also called fentanyl “nod,” and allows the person to better function throughout the day.
Additionally, potent, high-purity methamphetamine has widespread availability and affordability.
While OUD can be treated through multiple pathways, including medications such as buprenorphine, methadone and naltrexone, there are currently no medications available to treat methamphetamine.
“The lack of FDA-approved medications for stimulant use disorders limits the clinical tools that are available and increases the complexity and intensiveness of treatment regimens for those with co-occurring opioid and stimulant use disorders, as well as those with primary stimulant use disorders,” the report’s authors wrote.
While the report demonstrates that fentanyl users are increasingly ingesting methamphetamine, fentanyl remains “the main character of this terrible and devastating crisis,” Dawson said.
“This country lost over 110,000 people last year to drug overdose and the majority (80,000 or more) were fentanyl-related; fentanyl must remain our primary focus,” Dawson said. “However, now a growing number of deaths are being attributed to fentanyl with stimulants and thus we need to ensure solutions are aimed at both.”
