Is a new drug crisis looming?

The opioid crisis clearly has outpaced all other topics as the story of the year in addiction, and 2018 promises a repeat. Yet with all the justifiable attention to opioid addiction and overdose, is there danger that the next lurking trend in substance use will emerge as a full-blown epidemic before enough people notice?

In pockets of the country, including Florida, Maine and parts of the West, some research experts are pointing to recent increases in cocaine and methamphetamine arrests and deaths as evidence of what one observer calls a “smoldering” stimulant crisis. So far, the response from policy-makers and other leaders has been minimal.

“This will be big in the next 5 to 10 years if we don't look at it now,” says Stephanie Nichols, PharmD, associate professor of pharmacy practice at the Husson University School of Pharmacy in Bangor, Maine. The pharmacy school co-directed a study published in May in Pharmacotherapy that among its findings documented a 170% increase in methamphetamine arrests in Maine from 2015 to the first quarter of 2016.

“I don't think that stimulants have been a focus here at all,” says Nichols, as the effects of the opioid crisis continue to batter the New England states.

Jim Hall, an epidemiologist at Nova Southeastern University in Broward County, Fla., has been carrying a similar message, saying that the most recent national data show significant increases in cocaine- and methamphetamine-related deaths. Yet Hall also is quick to point out that policy-makers and the treatment community would be wise not to think in terms of one drug crisis being eclipsed by another, given the high prevalence of polysubstance use—sometimes not even known by the users themselves because of how common adulterants have become.

However, if the stimulant problem continues to gain momentum and become prominent across more of the country, this could end up becoming a vexing issue for treatment professionals. Unlike opioid addiction, where effective agonist and antagonist medications have become first-line treatment strategies that control cravings and offer a pathway to long-term recovery, there are no approved medication treatments for stimulant addiction. In fact, nothing in the pipeline appears very close to market.

The situation reminds Hall of the refrain he once heard from substance use treatment providers when cocaine was raging in South Florida back in the 1980s: “Give us back our heroin clients. We know what to do with them.”

Examining the numbers

An intelligence brief issued this year by the Drug Enforcement Administration (DEA) states that current market data show the highest cocaine supply levels in the U.S. since at least 2007, and the largest increase in domestic cocaine usage since at least 2009. “Barring a significant shift in the Government of Colombia's policies, drug trafficking organization behavior, or U.S. drug consumer preferences, this trend is likely to amplify through at least 2018,” the brief states.

The Centers for Disease Control and Prevention (CDC) reports that of the more than 64,000 drug overdose deaths estimated to have occurred in 2016, cocaine or methamphetamine was involved in more than 18,000 of the deaths. While the combined total for cocaine and methamphetamine is lower than the number of 2016 overdose deaths involving fentanyl and its analogs, cocaine- and methamphetamine-involved deaths have risen sharply over the past few years, at a time when prescription opioid-involved deaths have leveled off (heroin-involved deaths continue to rise).

Nova Southeastern University's Hall expresses great concern about data illustrating a growing prevalence of cocaine used in combination with an opioid. National statistics show that in 2010, the number of overdose deaths involving cocaine and opioids was equal to the number of overdose deaths involving cocaine without opioids. Since then, the number of deaths where both drugs were involved has more than doubled, while the number of deaths involving cocaine without opioids has increased by only 9%.

Hall says some users may know they are taking both drugs, but he adds that in a growing number of cases, a substance being sold as cocaine may also contain heroin or fentanyl. In crime lab data for Broward County in the first half of this year, eight of 32 samples of drug combinations contained cocaine with heroin, with another three made up of methamphetamine with heroin, Hall says.

He concludes from the present trends that it may be too optimistic to predict that one drug crisis will fade before another one flourishes.

“We no longer talk about drug of choice. We talk about polysubstance abuse,” Hall says. “More and more we have to be treating addiction as a disease rather than as a drug.”

In Maine, Husson University and two other educational institutions partnered with Diversion Alert, a statewide resource for drug arrest information, to report on drug abuse and arrest trends. While methamphetamine still accounts for less than 2% of all drug arrests in the state (by comparson, prescription opioids and heroin combine for around half of all drug arrests), methamphetamine arrests rose 170% in the first quarter of 2016 compared with 2015 data, Nichols confirms. Cocaine accounted for 16.1% of all drug arrests in the first quarter of 2016.

Nichols says prescriptions for stimulants such as methylphenidate and amphetamines have increased consistently in the state in recent years, nearly doubling from 2006 to 2014; that is consistent with reports from numerous other states' prescription drug monitoring program data. This leads to speculation over whether the stimulant problem could evolve in ways similar to the opioid crisis, where use of prescription drugs led the way early but where people turned to street drugs later, after a supply crackdown on prescription pain medication.

“Maybe people with a polysubstance use disorder who are cut off from both opioids and stimulants will turn to the street,” Nichols says. “These crises are very much related.”

Attention in treatment community

The Institute for the Advancement of Behavioral Healthcare recently conducted a survey of the audiences for Addiction Professional and the annual National Rx Drug Abuse and Heroin Summit, and found that trends in stimulant use are not going unnoticed in the treatment community.

Methamphetamine and amphetamines generally placed second behind opioids and heroin as drugs of concern in respondents' communities. While opioids and heroin were named as the drug of most concern by more than 68% of respondents, methamphetamine and amphetamines placed second at just over 16%, ahead of options such as benzodiazepines and marijuana.

Moreover, nearly 57% of the respondents checked off on the statement “The situation is deteriorating: More people are using stimulants.” That compared with around 37.5% who said stimulant use is stable and 5.5% percent who said fewer people are using stimulants. The survey overall garnered nearly 1,500 responses.

In another finding of note, survey participants tended to believe that while the level of attention to stimulant use was sufficient among treatment providers and in law enforcement, there has been less response overall from educators, the public health community, and government policy-makers.

Implications for providers

The absence of approved medication treatments for cocaine and other stimulant addiction certainly adds to the level of concern about the implications of a worsening stimulant problem. While there have been some promising developments in research, prospects for arrivals into the marketplace still appear years away.

Researchers and specialty pharmaceutical company Embera NeuroTherapeutics, Inc., have been examining the link between stress and addiction as they study whether a combination of the benzodiazepine oxazepam and the cortisol synthesis inhibitor metyrapone could become the breakthrough drug for cocaine dependence. While the original research grant in this area dates to 2010, best-case estimates would place a medication before the Food and Drug Administration (FDA) no sooner than 2023.

Similarly, there has been anticipation over development of an anti-cocaine vaccine that would activate an immune response in humans. This would mean that in any subsequent use of cocaine, the drug would be blocked from reaching the brain. Promising research on animals led to the launch of Phase I testing of the “dAd5GNE” vaccine in humans last year at New York-Presbyterian and Weill Cornell Medicine. But that trial probably will not be completed until 2019, and that would be only the first of several required steps toward an eventual approval.

In the meantime, those who closely watch emerging drug use patterns urge policy leaders and the treatment community to do the same. “It's really important for healthcare professionals to stay abreast of current trends,” says Nichols. “Trends can help us identify potential concerns before they become a huge problem.”

Hall, who has witnessed several drug crises in Florida over his career, also keeps in mind that some phenomena remain constant. “With these epidemics, alcohol has been there through all of them,” he says. “Certainly alcohol is one of the ingredients in the stomach's punch bowl of polysubstance use.”

To further explore this important topic, the Institute for the Advancement of Behavioral Healthcare is launching the National Cocaine, Meth & Stimulant Summit in 2018, along with a series of e-newsletters and webinars on this issue. For details on the upcoming conference, click here.