Stimulant/Opioid OD Deaths Prompt Calls for New Strategy

Jake Remaly

February 08, 2022

Rates of fatal overdoses from opioids combined with stimulants have increased the most in populations that historically have been considered less affected by opioid addiction in the United States, new research has found.

The findings suggest that overdose prevention efforts that focus on opioids alone may be of limited use when many people die from combining the painkillers with cocaine, methamphetamine, or other stimulants, experts said.

The new data highlight a need to rethink where and how agencies allocate resources for preventing drug overdoses, and whom these programs should help, according to the researchers, who published their study today in the American Journal of Epidemiology.

When the study investigators analyzed 2007-2019 National Center for Health Statistics death certificate data, they found "alarming trends," Tarlise Townsend, PhD, a postdoctoral researcher at the Center for Opioid Epidemiology and Policy at NYU Langone Health and the lead author of the study, told Medscape Medical News. "Not only further evidence that the combination of stimulants and opioids is causing massive increases in overdose deaths nationally, but that those increases are happening more severely in people from marginalized racial and ethnic communities."

Massive Surge in Death Rates

The rate of Black Americans dying from a combination of opioids and cocaine increased by 575% during the study period, whereas the rate for White Americans increased by 184% (from 0.60 to 4.05 deaths per 100,000 people [Black] vs 0.49 to 1.39 deaths per 100,000 (White)], the investigators reported.

Death rates involving methamphetamine or other stimulants remained lower than those involving cocaine, but the relative increase was steeper. Mortality linked to a combination of opioids and methamphetamine or other stimulants soared by 16,200% among Blacks and 3200% among Whites over the 12-year period. 

Overdose deaths could include intentional mixing of stimulants and opioids — to enhance a high, counterbalance unwanted effects of the other drug, or to help manage withdrawal symptoms — as well as cases in which people unwittingly use stimulants that contain opioids like fentanyl.

The new analysis showed that in the South, deaths from cocaine and opioids increased 26% per year among Black people, 27% per year among Latinx people, and 12% per year among non-Hispanic Whites.

Death rates from methamphetamine or other stimulants combined with opioids increased faster among Asian Americans and Pacific Islanders, relative to White Americans, in the West and Northeast, according to the investigators.

Among Latinx Americans, rates increased faster than those for White Americans in the West, Northeast, and upper Midwest. 

Addressing Polysubstance Use

People who primarily use stimulants may not identify as opioid users and may be less likely to access opioid-related harm reduction services like fentanyl test strips and take-home naloxone, Townsend said.

"Our findings bolster the argument that overdose prevention efforts should target not only people who use opioids, but also those who primarily use cocaine, methamphetamine, and other stimulants," senior author Magdalena Cerdá, DrPH, professor and director of the Center for Opioid Epidemiology and Policy, said in a press release. "Because of structural and systemic racism, adequate access to harm reduction and evidence-based substance use disorder treatment services is lacking in Black and Hispanic neighborhoods. More state and federal funding for these programs [is] needed."

Clinicians lack approved medications for stimulant use disorder. Evidence-based treatment in the form of contingency management is often unavailable. And evidence for how to best treat polysubstance use is lacking, the authors noted.

The researchers said they lacked adequate data from American Indian and Alaska Native populations to examine state-specific trends for these groups, but mortality may be "particularly high" in these populations and "may be increasing rapidly."

In fact, the death rates in those communities may be higher than in the other groups, and it is possible death rates would have increased relatively little because they were high to begin with, according to Richard A. Rawson, PhD, research professor at the University of Vermont, Burlington and professor emeritus at the University of California, Los Angeles.

In the past, clinicians might think about counseling and the possibility of relapse for patients with addiction. But with the currently available drug supply, particularly fentanyl, "we have to take a step back and focus on the issue of the deadliness of these drugs," including how they are disproportionately affecting Black and Hispanic communities, Rawson, who was not involved in the study, told Medscape.

The new study belongs "on the table of policy makers throughout the United States who are determining how to address the drug problems in their states or cities or counties" and can help them "recognize that extraordinary outreach needs to occur in those communities to better address these problems," he said.

To that end, California is launching a large-scale program providing contingency management for the treatment of stimulant use disorder. H. Westley Clark, MD, JD, MPH, with Santa Clara University, is advising the state on this effort.

Epidemiologic data tend to minimize the substance use experience of Asians, he said, but the study showed that while substance use tends to be lower than in other groups, it is not zero and it has increased.

"By looking at things geographically and by populations, you can begin to address these matters more aggressively and more appropriately," Clark said.

Ricky Bluthenthal, PhD, professor of population and public health sciences at USC's Keck School of Medicine in Los Angeles, has documented trends in the co-use of opioids and stimulants in California.

In 2013, roughly one third of people who used drugs said they used methamphetamine and heroin. By 2018, that figure was closer to 70%.

Although stimulants can cause fatal overdoses, synthetic opiates are likely the cause of many overdoses involving combinations of the drugs, Bluthenthal said.

The National Institute on Drug Abuse and the NYU Center for Opioid Epidemiology and Policy provided funding for the study. The study authors, Rawson, and Bluthenthal have disclosed no relevant financial relationships. Clark, through a university contract, is advising California on the implementation of a contingency management program. He is also an unpaid member of the Motivational Incentives Policy Group, which advocates for the adoption of contingency management.

Am J Epidemiol. Published online February 8, 2022. Abstract

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