Purpose of review

This review provides an update on recently published literature on the rise of illicit fentanyls, risks for overdose, combinations with other substances, e.g. stimulants, consequences, and treatment.

Recent findings

Overdose due to illicit synthetic opioids (e.g. fentanyl and fentanyl analogs) continues to rise in the US both preceding and during the COVID-19 pandemic. Fentanyl-related overdose is rising in new geographic areas e.g. the western USA. Stimulant-related overdose is also increasing nationwide driven by methamphetamine and cocaine. Polysubstance use, e.g. the use of a stimulant along with an opioid is driving stimulant-related overdose. Other medical consequences of injection drug use are rising including HIV and hepatitis C infections. Medication approaches to treating opioid use disorder remain the standard of care and there are new promising pharmacological approaches to treating methamphetamine use disorder.

Summary

A 'fourth wave' of high mortality involving methamphetamine and cocaine use has been gathering force in the USA. Availability and use of illicit fentanyls are still the major drivers of overdose deaths and the current rise in stimulant-related deaths appears entwined with the ongoing opioid epidemic.

The US mortality rate has gone up three years in a row from 2014 to 2017 (Murphy, Xu, Kochanek, & Arias, 2016, 2018; National Center for Health Statistics, 2017). Correspondingly, life expectancy at birth has declined; the first triple year decline since World War One and the devastating influenza pandemic one hundred years ago (Tejada Vera B, 2017). Most of the top ten causes of death are declining year over year; however, the third leading cause of death, unintentional injuries, has climbed in rate and rank since 2014 (Murphy et al., 2016). Driving this are deaths due to drug poisoning which exceeded 70,000 in 2017 (Hedegaard H, 2018). Annual deaths due to drug overdoses now exceed those from motor vehicle deaths, gun violence and even HIV at the height of the 1990s HIV epidemic (J Katz, 2017).

Extending from the triple wave epidemic of opioid-related overdose deaths, a fourth wave of high mortality involving methamphetamine and cocaine use has been gathering force. This article provides a review of the published literature on stimulants including epidemiology, pharmacology, neurobiology, medical and psychiatric consequences, withdrawal management, and medical and behavioral treatments.

The loss of functioning veins (venous sclerosis) is a root cause of suffering for long-term heroin injectors. In addition to perpetual frustration and loss of pleasure/esteem, venous sclerosis leads to myriad medical consequences including skin infections, for example, abscess, and possibly elevated HIV/HCV risks due to injection into larger jugular and femoral veins. The etiology of venous sclerosis is unknown and users' perceptions of cause/meaning unexplored. This commentary stems from our hypothesis that venous sclerosis is causally related to heroin acidity, which varies by heroin source-form and preparation. We report pilot study data on first ever in vivo measurements of heroin pH and as well as qualitative data on users' concerns and perceptions regarding the caustic nature of heroin and its effects. Heroin pH testing in natural settings is feasible and a useful tool for further research. Our preliminary findings, for example, that different heroin source-forms and preparations have a two log difference in acidity, have potentially broad, vital and readily implementable harm reduction implications.

This commentary revisits the political turmoil and scientific controversy over epidemiological study findings linking high HIV seroincidence to syringe exchange attendance in Vancouver in the mid-1990s. The association was mobilized polemically by US politicians and hard-line drug warriors to attack needle exchange policies and funding. In turn, program restrictions limiting access to syringes at the Vancouver exchange may have interfaced with a complex conjunction of historical, geographic, political economic and cultural forces and physiological vulnerabilities to create an extraordinary HIV risk environment: (1) ghettoization of services for indigent populations in a rapidly gentrifying, post-industrial city; (2) rural-urban migration of vulnerable populations subject to historical colonization and current patterns of racism; and (3) the flooding of North America with inexpensive powder cocaine and heroin, and the popularity of crack. In fact, we will never know with certainty the precise cause for the extreme seroincidence rates in Vancouver in the early to mid-1990s. The tendency for modern social epidemiology to decontextualize research subjects and assign excessive importance to discrete, "magic bullet" variables resulted in a counterproductive scientific and political debate in the late 1990s that has obfuscated potentially useful practical lessons for organizing the logistics of harm reduction services - especially syringe exchange - to better serve the needs of vulnerable populations and to mitigate the effects of political-economically imposed HIV risk environments. We would benefit from humbly acknowledging the limits of public health science and learn to recognize the unintended consequences of well-intentioned interventions rather than sweep embarrassing histories under the rug.

Background

US opioid overdose death rates have increased between 2000 and 2014. While, the increase in prescription opioid use has been linked to the increase in heroin use, there are reasons to view this relationship as a partial explanation for the recent increase in heroin-related harms. This study documents the differences in trends in prescription opioid overdose-related (POD) and heroin overdose-related (HOD) hospitalizations.

Methods

Data come from the National Inpatient Sample (NIS) for the years 2000 through 2014. POD and HOD hospitalizations were abstracted from ICD-9 codes. Rates of POD and HOD by census region and census division were constructed along with separate rates for age and race. Regression analysis analyzing trends across region were estimated along with graphs for documenting differences in POD and HOD rates.

Results

POD hospitalization rates were highest in the South and lowest in the Northeast. HOD hospitalization rates were highest in the Northeast region and grew the fastest in the Midwest. There was statistically significant heterogeneity in HOD trends but not POD trends across the four regions between 2000 and 2014. Between 2012 and 2014 POD rates decreased in eight of the nine census divisions, with only New England showing an increase. HOD hospitalization rates increased in all nine census divisions between 2012 and 2014. Both POD and HOD rates show different demographic patterns across the nine census divisions.

Conclusion

Comparing POD and HOD hospitalization trends reveals significant disparities in geographic as well as demographic distributions. These epidemics are evolving and the simple opioid-to-heroin transition story is both supported and challenged by this paper. The opioid pill, heroin and fentanyl crises are intertwined yet increasingly have drivers and outcomes that support examining them as distinct. Addressing these complex and interrelated epidemics will require innovative public health research and interventions which need to consider local and regional contexts.

BACKGROUND:Internationally, overdose is the primary cause of death among people injecting drugs. However, since 2001, heroin-related overdose deaths in the United States (US) have risen sixfold, paralleled by a rise in the death rate attributed to synthetic opioids, particularly the fentanyls. This paper considers the adaptations some US heroin injectors are making to protect themselves from these risks. METHODS:Between 2015 and 2016, a team of ethnographers collected data through semi-structured interviews and observation captured in field notes and video recording of heroin preparation/consumption. Ninety-one current heroin injectors were interviewed (Baltimore, n = 22; Chicago, n = 24; Massachusetts and New Hampshire, n = 36; San Francisco, n = 9). Experience injecting heroin ranged from < 1-47 years. Eight participants, who were exclusively heroin snorters, were also interviewed. Data were analyzed thematically. RESULTS:Across the study sites, multiple methods of sampling "heroin" were identified, sometimes used in combination, ranging from non-injecting routes (snorting, smoking or tasting a small amount prior to injection) to injecting a partial dose and waiting. Partial injection took different forms: a "slow shot" where the user injected a portion of the solution in the syringe, keeping the needle in the injection site, and continuing or withdrawing the syringe or a "tester shot" where the solution was divided into separate injections. Other techniques included getting feedback from others using heroin of the same batch or observing those with higher tolerance injecting heroin from the same batch before judging how much to inject themselves. Although a minority of those interviewed described using these drug sampling techniques, there is clearly receptivity among some users to protecting themselves by using a variety of methods. CONCLUSIONS:The use of drug sampling as a means of preventing an overdose from injection drug use reduces the quantity absorbed at any one time allowing users to monitor drug strength and titrate their dose accordingly. Given the highly unpredictable potency of the drugs currently being sold as heroin in the US, universal precautions should be adopted more widely. Further research is needed into facilitators and barriers to the uptake of these drug sampling methods.

Background

The US is experiencing an unprecedented opioid overdose epidemic fostered in recent years by regional contamination of the heroin supply with the fentanyl family of synthetic opioids. Since 2011 opioid-related overdose deaths in the East Coast state of Massachusetts have more than tripled, with 75% of the 1374 deaths with an available toxicology positive for fentanyl. Fentanyl is 30-50X more potent than heroin and its presence makes heroin use more unpredictable. A rapid ethnographic assessment was undertaken to understand the perceptions and experiences of people who inject drugs sold as 'heroin' and to observe the drugs and their use.

Methods

A team of ethnographers conducted research in northeast Massachusetts and Nashua, New Hampshire in June 2016, performing (n=38) qualitative interviews with persons who use heroin.

Results

(1) The composition and appearance of heroin changed in the last four years; (2) heroin is cheaper and more widely available than before; and (3) heroin 'types' have proliferated with several products being sold as 'heroin'. These consisted of two types of heroin (alone), fentanyl (alone), and heroin-fentanyl combinations. In the absence of available toxicological information on retail-level heroin, our research noted a hierarchy of fentanyl discernment methods, with embodied effects considered most reliable in determining fentanyl's presence, followed by taste, solution appearance and powder color. This paper presents a new 'heroin' typology based on users' reports.

Conclusion

Massachusetts' heroin has new appearances and is widely adulterated by fentanyl. Persons who use heroin are trying to discern the substances sold as heroin and their preferences for each form vary. The heroin typology presented is inexact but can be validated by correlating users' discernment with drug toxicological testing. If validated, this typology would be a valuable harm reduction tool. Further research on adaptations to heroin adulteration could reduce risks of using heroin and synthetic opioid combinations.