Stimulant users hit by deadly ‘fourth wave’ of opioid epidemic: Shots

A middle-aged man smokes crack cocaine in Rhode Island. The state had the fourth-highest rate of cocaine overdose deaths in the nation in 2022.

A middle-aged man smokes crack cocaine in Rhode Island. The state had the fourth-highest rate of cocaine overdose deaths in the nation in 2022.

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In Pawtucket, Rhode Island, near a store advertising “free” cell phones, JR sat in an empty back stairwell and showed a reporter how he tries to avoid an overdose by smoking crack cocaine.

(NPR calls him by his initials because he fears being arrested for using illegal drugs.)

It had been a few hours since his last hit, and the talkative, middle-aged man’s hands were moving quickly. In one hand he held a glass pipe. In the other, a crumb of cocaine the size of a lentil.

Or at least JR hoped it was cocaine, pure cocaine – not contaminated with fentanyl, a powerful opioid linked to nearly 80% of all overdose deaths in Rhode Island in 2022.

He flicked his lighter to “test” his stash. If it had a “cigar-like sweet smell,” he said, that meant his cocaine was laced with “fetty,” or fentanyl. He put the pipe to his lips and took a cautious drag. “No sweetness,” he said reassuringly.

But this “method” he devises only offers false — and dangerous — reassurance. It is virtually impossible to know for sure whether a drug contains fentanyl by taste or smell. And a mistake can be fatal.

“Someone may believe that he can smell it [fentanyl] “Or taste it, or see it… but that’s not a scientific test,” said Dr. Josiah “Jody” Rich, an addiction expert and researcher who teaches at Brown University. “People are dying today because they’re buying cocaine and they don’t know it has fentanyl in it.”

The mix of stimulants like cocaine and methamphetamine with fentanyl — a synthetic opioid 50 times more potent than heroin — is driving what experts are calling the “fourth wave” of the opioid epidemic. The mix poses a major challenge to overdose reduction efforts because many stimulant users are unaware that they are at risk of taking opioids and so don’t take overdose precautions.

The only way to know if cocaine or other stimulants contain fentanyl is to use drug-testing tools like fentanyl testing strips — a harm-reduction best practice now being embraced by federal health officials to combat drug overdose deaths. Fentanyl testing strips cost as little as $2 for a two-pack online, but many frontline organizations are also giving them away for free.

A test kit used to detect the powerful opioid fentanyl in a cocaine sample.

A test kit used to detect the powerful opioid fentanyl in a cocaine sample.

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In the US, the first wave of the long and devastating opioid epidemic began with the abuse of prescription painkillers (early 2000s); the second wave included a rise in heroin use, which began around 2010.

The third wave began around 2015 when powerful synthetic opioids such as fentanyl entered the market.

Now, experts are observing a fourth phase of the deadly epidemic. Nationwide, illicit stimulants laced with fentanyl were the most common drugs found in fentanyl-related overdoses, according to a study published in 2023 in the journal Scientific Reports Addiction.

In the Northeast, the stimulant in this deadly mixture is usually cocaine, and in the West and much of the Midwest and South, it is methamphetamine.

“The most common cause of drug overdoses in the U.S. is the combination of fentanyl and a stimulant,” said Joseph Friedman, a UCLA researcher and lead author of the study.

“Black and African Americans are being disproportionately affected by this crisis, especially in the Northeast.”

Factors Causing Polydrug Overdoses

It’s unclear how much of the latest trend in polydrug use is accidental or intentional. A recent study from Millennium Health found that most people who use fentanyl sometimes do so intentionally and sometimes unintentionally.

People often use stimulants to get through the rapid withdrawal from fentanyl, Friedman said. And the risky practice of mixing cocaine or meth with heroin, known as speedballing, has been around for decades.

Other factors include manufacturers adding the cheap synthetic opioid to a stimulant to extend supply, or dealers switching bags.

But in Rhode Island, many people still think they’re using genuine cocaine or crack, researchers say — a misconception that can be deadly.

Stimulant users unprepared for fentanyl’s ubiquity

“People who use stimulants, and not opioids intentionally, are not prepared for opioid overdose … because they don’t perceive themselves as being at risk,” said Jaclyn White Hughto, an epidemiologist at Brown University and lead researcher in a new, unpublished study called Preventing Overdoses Involving Stimulants.

The researchers interviewed more than 260 drug users in Rhode Island and Massachusetts, including people who produce and distribute stimulants such as cocaine.

More than 60% of respondents in Rhode Island had purchased or used stimulants that were later found to contain fentanyl.

According to the U.S. Centers for Disease Control and Prevention (CDC), Rhode Island had the fourth highest number of cocaine overdose deaths in 2022, after DC, Delaware and Vermont.

People who do not use opioids regularly have a lower tolerance to opioids, putting them at greater risk of overdose.

Furthermore, many of the respondents in the study also use drugs alone, so if they do take an overdose, they may not be found until it is too late.

Jennifer Dubois, a single mother whose 19-year-old son, Clifton, died of an overdose in 2020. The counterfeit Adderall pill he was taking contained the powerful opioid fentanyl.

Jennifer Dubois, a single mother whose 19-year-old son, Clifton, died of an overdose in 2020. The counterfeit Adderall pill he was taking contained the powerful opioid fentanyl.

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Dubois was a single mother raising two black sons. The oldest son, Clifton, had struggled with substance abuse since he was 14, she said. Clifton also had been diagnosed with ADHD and a mood disorder.

In March 2020, Clifton had just checked into a rehabilitation program when the pandemic flared up, Dubois said.

Because of the lockdown in rehab, Clifton was upset that he couldn’t visit his mother. “He said, ‘If I can’t see my mom, I can’t get treatment,'” Dubois recalled. “And I begged him to stay in treatment.”

But shortly after, Clifton left the rehab program. He showed up at her door. “And I just cried,” she said.

Dubois’ youngest son lived at home. Dubois didn’t want Clifton using drugs around his younger brother. So she gave Clifton an ultimatum: “If you want to stay home, you have to stay drug-free.”

Clifton went to stay with family friends, first in Atlanta and later in Woonsocket, an old factory town with the highest rate of drug overdose deaths in Rhode Island.

In August 2020, Clifton overdosed but was brought back to consciousness. Clifton later said he had snorted cocaine in a car with a friend, Dubois said.

Hospital records show he tested positive for fentanyl.

“He was really scared,” Dubois said. After the overdose, he tried to “stay away from the cocaine and the hard drugs,” she said. “But he was taking pills.”

Eight months later, on April 17, 2021, Clifton was found unconscious in a family member’s bedroom.

The night before, Clifton had purchased counterfeit Adderall, according to the police report. What he didn’t know was that the Adderall pill was laced with fentanyl.

“He thought he could do better by staying away from street drugs … and just taking pills,” Dubois said. “I really believe Cliff thought he was taking something safe.”

A memorial plaque in downtown Woonsocket, RI in 2023, by friends of Jennifer Dubois. The plaque depicts her 19-year-old son, Clifton, who died of a drug overdose in 2020.

A memorial plaque in downtown Woonsocket, RI in 2023, by friends of Jennifer Dubois. The plaque depicts her 19-year-old son, Clifton, who died of a drug overdose in 2020.

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The opioid epidemic is driving up death rates among older Black Americans (ages 55-64) and, more recently, among Hispanics, according to a study recently published in The American Journal of Psychiatry.

But it’s too simplistic to focus just on whether fentanyl is present or not, said Joseph Friedman, a UC San Diego researcher and author of the study.

Hospitals have been safely using medical fentanyl for surgical pain for years because its strength is strictly regulated.

“It’s not the potency of fentanyl that’s risky,” he said. “It’s the fact that the potency fluctuates wildly on the illicit market.”

Research into street drugs shows that the strength of illegal drugs can range from 1% to 70% fentanyl.

“Imagine you go to a bar and order a mixed drink and it has one to 70 shots in it,” Friedman said, “and the only way to find out is to drink it… There would be a huge number of alcohol overdose deaths.”

He says drug-monitoring technology can provide a rough estimate of fentanyl concentration, but to get an accurate reading, the drugs must be sent to a lab.

Fentanyl test strips are an inexpensive way to prevent overdoses. They detect the presence of fentanyl, regardless of strength, in cocaine and other illegal drugs.

In Rhode Island, test kits are available for free from harm reduction organizations such as Project Weber/Renew.

But the test strips only work if people use them — and then don’t use the drugs if they test positive for fentanyl. And not enough people who use stimulants do that.

This story comes from NPR’s health reporting partnership with The public radio And KFF Health News.

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