Concurrent Use of Stimulants, Opioids Complicates Policy Initiatives

There is broad agreement that concurrent use of stimulants and opioids is continuing to grow among drug users seen in addiction treatment programs. Judging from comments from experts and care providers in the opening session at the Cocaine, Meth & Stimulant Summit in Miami, pinning down the main source of this trend is still eluding observers, however.

A session led by Ohio University visiting professor and former state substance use services director Orman Hall featured enthusiastic audience input and two major theories as to what's driving the trend. First, there is growing evidence of contamination of stimulants with opioids, exposing users unwittingly to potentially deadly fentanyl. However, several care providers at the conference reported strong indications that some users are intentionally switching back and forth between stimulants and opioids, perhaps to counteract the effects of each.

“Stimulants typically have been less fatal than opioids, but contamination is causing higher levels of overdose and death,” Hall said. “If fentanyl contamination of stimulants becomes more common, this could be a catastrophe in your areas.”

The opening session of the second annual Stimulant Summit touched on an important theme that has prevailed throughout the first two events: the need to improve tracking systems to give policy-makers, the public health community and treatment professionals more timely insight to inform their drug-fighting initiatives.

Hall pointed out that in his home state of Ohio, fentanyl began to surface as a crisis in 2014, but universal testing for fentanyl did not start happening in drug court and treatment programs until three years later.

The numbers are telling

Hall, a consultant to the Ohio High-Intensity Drug Trafficking Area (HIDTA), shared some compelling statistics that illustrate the growing concern over stimulant trends. The vast majority of drug seizures across the HIDTA network nationally in 2018 were for cocaine and methamphetamine as opposed to opioids, he said. He pointed out several particular locations of concern, including the Appalachian region, South Florida, Michigan and West Texas.

He said New York City officials largely attributed a spike in cocaine-related deaths in 2014-16 to contamination of the cocaine supply with fentanyl.

But leaders are still wrestling with the question of how many users are intentionally combining use of stimulants and opioids, a practice that exacerbates risk of the most adverse consequences. Audience members from Wisconsin and upstate New York both suggested that intentional concurrent use might be more prevalent than unwitting use of a contaminated product in their communities.

Federal outlook

Officials with the Food and Drug Administration (FDA), the Centers for Disease Control and Prevention (CDC) and the U.S. Department of Justice closed the summit's first day with a session that suggested increased federal government engagement on stimulant trends.

Marta Sokolowska, PhD, associate director for controlled substances at the FDA, announced that the agency is holding two policy meetings on development of drug therapies to treat stimulant addiction: a Dec. 16 event to help identify paradigms for development of novel therapies, and a March 10 public meeting where patients will be asked about how they choose among various treatment options. There is no currently approved medication treatment for stimulant addiction.

Sokolowska cited Treatment Episode Data Set (TEDS) statistics from 2008-17 that showed a nearly 500% increase in methamphetamine use among patients admitted to treatment primarily for heroin use. She added that these dual admissions are 35% less likely to have medication treatment for opioid addiction included in their treatment plan.