From the Blog of Dr. Nora Volkow,
National Institute on Drug Addiction
November 12, 2020
Although we often talk about individual drugs and drug use disorders in isolation, the reality is that many people use drugs in combination and also die from them in combination. Although deaths from opioids continue to command the public’s attention, an alarming increase in deaths involving the stimulant drugs methamphetamine and cocaine are a stark illustration that we no longer face just an opioid crisis. We face a complex and ever-evolving addiction and overdose crisis characterized by shifting use and availability of different substances and use of multiple drugs (and drug classes) together.
Overdose deaths specifically from opioids began escalating two decades ago, after the introduction of potent new opioid pain relievers like OxyContin. But actually, drug overdose deaths have been increasing exponentially since at least 1980, with different substances (e.g., cocaine) driving this upward trend at different times. Overdose deaths involving methamphetamine started rising steeply in 2009, and provisional numbers from the CDC show they had increased 10-fold by 2019, to over 16,500. A similar number of people die every year from overdoses involving cocaine (16,196), which has increased nearly as precipitously over the same period.
Although stimulant use and use disorders fluctuate year to year, national surveys have suggested that use had not risen considerably over the period that overdoses from these drugs escalated, which means that the increases in mortality are likely due to people using these drugs in combination with opioids like heroin or fentanyl or using products that have been laced with fentanyl without their knowledge. Fentanyl is a powerful synthetic opioid (80 times more potent than morphine) that since 2013 has driven the steep rise in opioid overdoses.
During the last half of the 1980s, when cocaine surged in popularity, many overdoses occurred in people combining this drug with heroin. The recent rise in deaths from co-use of stimulants and opioids seems to reflect a similar phenomenon. According to a recent examination of barriers to syringe services programs published in the International Journal of Drug Policy, staff at some programs report that increasing numbers of individuals are injecting methamphetamine and opioids together. Some also report that individuals are switching from opioids to methamphetamine because they fear the unpredictability of opioid products that may contain fentanyl (even though methamphetamine may be laced with fentanyl too).
Much more research is needed on the co-use of stimulants and opioids as well as how their combination affects overdose risk. Unfortunately, death certificates do not always list the drugs involved, and when they do, they may not always be accurate about which drugs principally contributed to mortality, making it difficult to know exactly the role opioids and stimulants play in mortality when people deliberately or unknowingly take the two together.
Overdose is not the only danger. Persistent stimulant use can lead to cognitive problems as well as many other health issues (such as cardiac and pulmonary diseases). Injecting cocaine or methamphetamine using shared equipment can transmit infectious diseases like HIV or hepatitis B and C. Cocaine has been shown to suppress immune-cell function and promote replication of the HIV virus and its use may make individuals with HIV more susceptible to contracting hepatitis C. Similarly methamphetamine may worsen HIV progression and exacerbate cognitive problems from HIV.
Efforts to address stimulant use should be integrated with the initiatives already underway to address opioid addiction and opioid mortality. The complex reality of polysubstance use is already a research area that NIDA funds, but much more work is needed. The recognition that we face a drug addiction and overdose crisis, not just an opioid crisis, should guide research, prevention, and treatment efforts going forward.
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