US enters 'fourth wave' of opioid crisis, mixing fentanyl with stimulants

The most recent phase is characterized by the concurrent use of various substances, primarily fentanyl mixed with either methamphetamine or cocaine, according to the report's findings.

US enters 'fourth wave' of opioid crisis, mixing fentanyl with stimulants
AP Photo/Lindsey Wasson
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The United States finds itself deeply embroiled in what some specialists describe as the 'fourth wave' of the opioid crisis. This phase is heightening the dangers for drug users and adding complexity to the challenge of tackling the country's drug issue, as reported by American Military News.

A recent report from Millennium Health outlines the progression of this crisis, starting with the widespread misuse of prescription opioids. This was succeeded by a surge in heroin consumption and subsequently followed by the rise in synthetic opioid usage, such as fentanyl.

The most recent phase is characterized by the concurrent use of various substances, primarily fentanyl mixed with either methamphetamine or cocaine, according to the report's findings.

Eric Dawson, the vice president of clinical affairs at Millennium Health and one of the report's co-authors said that he's "yet to see a peak." Millennium Health is a specialized lab offering drug testing services to track the usage of prescription medicines and illegal drugs.

The report conducts an extensive analysis of drug trends across the United States, detailing consumption habits by region. It is grounded in the analysis of 4.1 million urine samples collected between January 2013 and December 2023 from individuals undergoing drug addiction treatment.

The data reveal astonishing figures and insights, with a particular emphasis on the prevalence of polysubstance use. The report highlights a significant finding: a vast majority of fentanyl-positive urine samples—almost 93%—tested positive for additional substances.

"That is huge," remarked Nora Volkow, the director of the National Institute on Drug Abuse at the National Institutes of Health.

Volkow and other experts in addiction expressed alarm over the sharp rise in the concurrent use of methamphetamine and fentanyl. Methamphetamine, an extremely addictive substance typically found in powder form that carries significant cardiovascular and psychiatric dangers, was detected in 60% of fentanyl-positive tests in the last year. This represents an 875% surge in such cases since 2015.

“I never, ever would have thought this,” Volkow said.

The report uncovers several significant insights:

  • The surge in methamphetamine consumption along with fentanyl across the country indicates a shift in patterns of drug use.
  • The practice of consuming multiple drugs simultaneously introduces complications in treating overdoses. Although naloxone, a drug used to counteract opioid overdoses, is broadly accessible, there is currently no FDA-sanctioned treatment for overdoses on stimulants.
  • The use of heroin and prescription opioids in conjunction with fentanyl has decreased. The detection of heroin in tests positive for fentanyl has fallen by 75% since its highest point in 2016. Furthermore, the incidence of prescription opioids in fentanyl-positive screenings reached record lows in 2023, with an 89% reduction since 2013.

However, Jarratt Pytell, an expert in addiction medicine and assistant professor at the University of Colorado’s School of Medicine, cautioned against viewing these decreases as a positive development.

A lower level of heroin use “just says that fentanyl is everywhere,” Pytell said, “and that we have officially been pushed by our drug supply to the most dangerous opioids that we have available right now.”

“Whenever a drug network is destabilizing and the product changes, it puts the people who use the drugs at the greatest risk,” he said. “That same bag or pill that they have been buying for the last several months now is coming from a different place, a different supplier, and is possibly a different potency.”

In the illegal drug trade, suppliers hold the reins. The trend may not be driven by users specifically seeking methamphetamine and fentanyl, but instead by what drug suppliers have determined to be the most straightforward and profitable products to distribute.

“I think drug cartels are kind of realizing that it’s a lot easier to have a 500-square-foot lab than it is to have 500 acres of whatever it takes to grow cocaine,” Pytell said.

Dawson highlighted that the drug usage data in the report, unlike other studies, is derived from sample analyses that are processed quickly—within a day or two.

Researchers often endure a months-long wait for death reports from coroners. In such situations, “staring at today but relying on data sources that are a year or more in the past,” Dawson said.

Jonathan Caulkins, a professor at Carnegie Mellon University’s Heinz College, noted that self-reported surveys of drug users, another common method for tracking drug use, also suffer from long delays and "often miss people who are active for substance use disorders." In contrast, urine tests "are based on a biology standard" and excel at identifying instances where someone has used multiple drugs.

However, there are inherent drawbacks to relying on data from urine samples. Notably, these tests do not disclose the users' intentions.

“You don’t know whether or not there was one bag of powder that had both fentanyl and meth in it, or whether there were two bags of powder, one with fentanyl in it and one with meth and they took both,” Caulkins said.

He added that it can also be ambiguous whether individuals intentionally mixed the two drugs for an enhanced effect or if they believed they were consuming only one, unaware it was laced with the other.

Volkow said she is interested in learning more about the demographics of polysubstance drug users. “Is this pattern the same for men and women, and is this pattern the same for middle-age or younger people? Because again, having a better understanding of the characteristics allows you to tailor and personalize interventions.”

Throughout this period, the country's emergency persists. The Centers for Disease Control and Prevention report that in 2021, over 107,000 individuals in the U.S. lost their lives to drug overdoses, with fentanyl being the primary cause for the majority of these deaths.

Caulkins expressed reservations about describing the trends in drug consumption as sequential waves, suggesting that it would indicate a progression from one type of drug use to another.

“Are we looking at people whose first substance use disorder was an opioid use disorder, who have now gotten to the point where they’re polydrug users?” he said. Or, are people now starting substance use disorders with methamphetamine and fentanyl, he asked.

One point was clear, Dawson said: “We’re just losing too many lives.”

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