Stimulant Summit | Volkow: Fentanyl Driving Increase in Cocaine-Involved Deaths

Deaths associated with psychostimulant drug use are on the rise across the United States, and understanding what is driving shifts in the choice of drugs people are being exposed to is crucial for preventing them, Nora Volkow, MD, director of the National Institute on Drug Abuse, told Cocaine, Meth & Stimulant Summit attendees in a session presented on Thursday.

Looking at surveys of drug use in the US from 2016 to 2019, the number of individuals reporting cocaine use has remained fairly consistent, which suggests that increases in mortality are a result of individuals being exposed to cocaine that is more dangerous than what had been previously used, Dr Volkow said. A likely culprit is the presence of fentanyl, as deaths involving cocaine in combination with opioids have increased while cocaine-involved deaths without the presence of opioids have remained relatively stable.

“In many instances, users do not know they are buying cocaine that has been contaminated with fentanyl,” Dr Volkow said.

Meanwhile, methamphetamine use among the 26-and-older population is on the rise, likely contributing to increases in mortality associated with methamphetamine overdoses. Methamphetamine-involved deaths are increasing in parallel to the overall consumption of methamphetamine in the US.

Black, non-Hispanic individuals have been found to have the highest mortality rate associated with cocaine use, while for methamphetamine, the mortality rate is much greater among Native Americans and Alaskan Natives than the general population.

“This is important because interventions that are targeted towards treatment or prevention need to take into account the greater vulnerability of some racial groups and ethnic groups for these types of drugs and for overdoses,” Dr Volkow said. “It’s very relevant as we think about the history of the opioid crisis that initially, basically, the mortality was afflicting predominately White Americans.

“That has changed. We now know that the group with the highest rate of mortality and which is increasing the fastest are among Black Americans. This is linked both with cocaine mixed with opioids as well as with opioids themselves.”

Stimulant Trends During the Pandemic

Dr Volkow said that she initially theorized that border closures enacted to reduce the spread of COVID-19 would make it more difficult to bring illicit drugs into the US. In the past year and a half, though, data show that things haven’t played out that way.

Drug seizures at US borders did not decrease in 2020, and in the case of methamphetamine, a dramatic jump was actually observed. Increases in access to fentanyl, methamphetamine and cocaine “are likely to be very problematic and exacerbating, rather than what we may have predicted,” Dr Volkow said.

Treatment Options

While medications have proven effective in treating opioid use disorder, no medications have yet received FDA approval for treating cocaine or methamphetamine use disorder, making it much more challenging to treat such psychostimulant use disorders, Dr Volkow said.

“There is evidence that behavioral therapies, particularly contingency management, combined with a community reinforcement approach, significantly improves outcomes,” Dr Volkow said. “If there is a message to be sent, it is that while we have no medications, we have behavioral interventions for which the evidence clearly shows benefits, but for which the challenge is, in many instances, that these are not being implemented.”

Dr Volkow said that while there currently are no overdose reversal medications available for methamphetamine or cocaine, similar to naloxone for opioid overdose, developing such medications has become a research priority for the National Institute on Drug Abuse.

In the meantime, identifying medications already available that could be repurposed for treating cocaine or methamphetamine use disorder is a low-hanging fruit being explored. An example of this strategy, Dr Volkow said, is the combination of naltrexone (approved for treating alcohol and opioid use disorders) and bupropion (used to treat nicotine addiction). That combination has been shown to significantly improve outcomes of retention in treatment and abstinence in individuals with moderate to severe methamphetamine use disorders, Dr Volkow said.

Currently, vaccines are being tested in humans for both cocaine and opioid use disorder. While a vaccine for methamphetamine use disorder is not yet being tested in humans, “a very promising” monoclonal antibody against methamphetamine is in the works, Dr Volkow said.

“The beauty of the administration of monoclonal antibodies for methamphetamine is that you can administer them at higher doses,” Dr Volkow said. “This could be, potentially, an intervention that could be valuable for addressing methamphetamine overdoses where you could give the monoclonal antibodies and completely stop the action of the methamphetamine.”

Meanwhile, NIDA is also conducting work around the use of neuromodulation technologies, such as transcranial magnetic stimulation, to directly activate regions of the brain weakened by drug use, including the prefrontal cortex. This treatment modality is likely to be valuable for a variety of drug addictions, which is critical as more individuals are exposed to multiple drugs simultaneously Dr Volkow said.

While treatment interventions and overdose reversals are crucial, Dr Volkow concluded her presentation by noting that prevention efforts are even more important. Stress is one of the largest drivers of substance use, and having a strong support system to engage with socially can help build resilience. Interacting with one another is “the most powerful tool we have,” Dr Volkow said.

“If we discriminate, as it’s frequently the case for people seeking help for their substance use disorder or seeking harm-reduction practices, when they are mistreated, that is a form of punishment,” Dr Volkow said. “Thus, instead of helping the individual, it’s going to exacerbate the problem.

“If we want people to be successful in treatment, and importantly, if we want to prevent future epidemics like that one that we currently have, we have to build the social structure of our society to provide resilience and get rid of stigma.”

Reference

Volkow N. Research treatments for stimulant use disorder-insight from the National Institute on Drug Abuse. Presented at: Cocaine, Meth & Stimulant Summit; October 14-16, 2021; Virtual.