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.