Fentanyl Has Become a Prominent Danger for Stimulant Users

An analysis of 1 million urine drug test results has found steep increases in the presence of non-prescribed fentanyl in tests that are positive for cocaine or methamphetamine. The report from drug testing company Millennium Health adds to the accumulating evidence that the presence of fentanyl has become an important concern for the stimulant-using population as well as for opioid users.

What these analyses cannot pinpoint is the degree to which use of fentanyl in the stimulant-using population reflects unwitting use of adulterated cocaine and methamphetamine or intentional “speedballing” of a stimulant and an opioid together. Nonetheless, the results of the Millennium Health study and other recent analyses suggest that some of the overdose prevention strategies that target opioid users likely should be extended to the stimulant-using population as well.

For example, “The stimulant user population may benefit from access to naloxone,” Leah LaRue, PharmD, Millennium Health's associate director of clinical affairs, tells Addiction Professional.

Details of analysis

Published online April 26 in JAMA Network Open, the study looked at patient specimens submitted between January 2013 and September 2018 for urinalysis by a wide variety of health providers, including substance use treatment programs but also primary care practices, pain management providers and others. The median age of the population studied was 44, and 55% were women.

Total rates of positives were 4% for cocaine, 3.1% for methamphetamine and 1.4% for fentanyl. However, among tests positive for cocaine, the presence of non-prescribed fentanyl increased from 0.9% in 2013 to 17.6% in 2018 (an increase of 1,850%), and the presence of non-prescribed fentanyl in tests positive for methamphetamine increased from 0.9% in 2013 to 7.9% in 2018 (an increase of 798%.

“The magnitude was surprising,” LaRue says of the increases.

Looking at 2018 data specifically, the researchers found that rates of non-prescribed fentanyl in cocaine were highest in specimens collected from substance use treatment programs, and rates of non-prescribed fentanyl in methamphetamine were second highest in specimens collected from substance use treatment programs.

Authors of the study wrote that “clinicians need to be aware that patients presenting for treatment for suspected drug overdose or substance use disorder may have been exposed, knowingly or unknowingly, to multiple substances, including the combination of stimulants and opioids.”

Serious health risks

The authors pointed out that regardless of whether the use of fentanyl among stimulant users is intentional, dependence and overdose risk is heightened when these drugs are combined. For stimulant users who may be opioid-naive before being exposed to fentanyl, adverse effects may be greater because of a lack of opioid tolerance.

While the question of whether most of this concomitant use is attributable to unwitting use or intentional speedballing remains largely open, LaRue says these findings at least point to an opportunity for substance use treatment professionals to educate patients and other health providers about the relevant risks.

The term “speedballing” in the past has generally referred to intentional use of heroin and cocaine together. This phenomenon has been significantly more prominent than intentional co-use of heroin and methamphetamine, which some refer to as “goofballing.”