For the first time, methamphetamines and cocaine have overtaken heroin and prescription opioids in illicit drug use involving fentanyl nationwide and in nearly every state, a new report suggested.
The use of methamphetamine among people who also use fentanyl reached a record high in 2023, urinary drug tests (UDTs) showed, while the use of prescription opioids in that same group reached an historic low.
Investigators said the data offer further evidence that the US is experiencing a predicted “fourth wave” of the opioid crisis.
The report came on the heels of new data from the Centers for Disease Control and Prevention (CDC) that showed the preferred method of fentanyl-related illicit drug use shifted from intravenous injection to smoking.
“The rise in cocaine and methamphetamine nationally does not seem to be driven by one or even a few regions of the country,” authors of the 2024 Health Signals Report wrote. “Stimulants are a serious national challenge emphasizing the need for continued progress on the national plan to address methamphetamine supply, use, and consequences.”
The report, published online on February 22 by San Diego–based drug testing lab Millennium Health, is an analysis of urine specimens from 4.1 million unique patients aged ≥ 18 years, collected in all 50 states from 2013 to 2023.
A Year of Firsts
Last year, 60% of specimens that contained fentanyl also contained methamphetamine, an increase of 875% since 2015, according to Millennium’s report. It’s the first time that methamphetamine and cocaine were detected more often in urine drug tests than heroin and prescription opioids.
About a quarter of fentanyl-positive specimens also contained cocaine, 17% heroin and just 7% prescription opioids.
Almost all the fentanyl-positive specimens were positive for at least one additional substance; almost half contained three or more. Xylazine, an animal sedative known as “tranq,” was detected in nearly 14% of fentanyl-positive specimens.
“These combinations increase overdose vulnerability and may lessen responses to overdose reversal agents, making treatment as challenging as any time in history,” Millennium Senior VP and Chief Clinical Officer, Angela G. Huskey, PharmD, CPE, said in a statement.
The Millennium data back up what has been increasingly reported by the CDC and others. As reported in September by this news organization, in 2010, stimulants were co-involved in less than 1% of fentanyl overdose deaths. By 2021, stimulant-fentanyl use accounted for 32% of all fatal fentanyl overdoses.
In July 2023, the CDC reported a significant spike in overdose deaths involving cocaine or other psychostimulants and opioids from 2011 to 2021. In 2021, 79% of overdose deaths involving cocaine also involved an opioid and 66% of overdose deaths involving psychostimulants also involved an opioid, according to the CDC.
There were more overdose deaths from stimulants combined with opioids than from opioids alone in 2022, according to the CDC’s State Unintentional Drug Overdose Reporting System, which includes reports from 30 jurisdictions.
Smoking Overtakes Injection
The route of administration for opioids and stimulants — whether used alone or in combination, has also changed, the CDC recently reported. In 2022, just 16% of overdose deaths involved injection drug use, down from 23% in 2020, according to the analysis, which included data from 28 jurisdictions. For deaths involving illegally manufactured fentanyl, just 12% of deaths involved IV drug use.
By 2022, “smoking was the most commonly documented route of use in overdose deaths,” CDC researchers wrote in their report. Almost a quarter of deaths that year involved smoking.
The increase in smoking was seen for all substances, including opioids, fentanyl and combinations of fentanyl and stimulants, reported the agency.
Users might be switching to smoking from injections because there is a perception of fewer adverse health effects such as abscesses, reduced cost and stigma, sense of more control over quantity consumed per use, and “a perception of reduced overdose risk,” the researchers wrote.
Smoking still “carries substantial overdose risk because of rapid drug absorption,” they added.
Some harm reduction programs are adapting to the change in use patterns by providing safer smoking supplies and by changing messaging to warn of the dangers associated with smoking drugs, the CDC report noted.
A version of this article appeared on Medscape.com.