Newest phase in opioid epidemic: Mix of opioids and stimulants like coke and meth

Minnesota health officials and researchers are tracking a troubling trend in the opioid crisis, even amid a decline in the total number of opioid-involved deaths.

A recent rise in overdose deaths involving multiple drugs — like methamphetamine and opioids together — signals that we’ve potentially entered a new phase in the epidemic, due in part to the prevalence of substances laced with synthetic opioids like fentanyl, said Minnesota Department of Health official Dana Farley. 

This shift and other ongoing issues — including racial disparities and limited access to treatment — pose challenges to curbing the overall crisis.

“There are indications that the opioid crisis may be … metastasizing to other substances,” said Colin Planalp, a University of Minnesota researcher. 

Evidence suggests the rising number of deaths from psychostimulants like cocaine and methamphetamine is linked to the opioid epidemic, Planalp said. Federal Centers for Disease Control data shows half of psychostimulant-involved deaths in 2017 also involved opioids. 

Non-opioid drugs mixed with fentanyl — often without the users’ knowledge — are to blame for many of the multi-substance overdose deaths, Farley said.  “It truly is consumer beware.”

Opioid-involved overdose deaths drop in Minnesota; psychostimulant deaths level from 2017

Evidence suggests the recent rise in overdose deaths involving psychostimulants, like methamphetamine, are linked to the opioid epidemic, said Colin Planalp, researcher with the State Health Access Data Assistance Center.

This shift is significant in Minnesota, where psychostimulants are “especially a problem,” Planalp said.

Treating psychostimulant addiction can be challenging because there aren’t medications approved to help with recovery, like the drugs methadone and buprenorphine for opioid use disorders, he said.

“We don’t have great treatments for methamphetamine, and [treatment] really depends on the person, where it fits with them in terms of their … social context,” said Dr. Lucien Gonzalez of the University of Minnesota Medical School. 

Lower overall overdose death rate ‘masks meaningful numbers’ in Minnesota

Opioid overdose deaths in Minnesota peaked at a total of 422 in 2017, then dropped roughly 22% the following year, according to preliminary 2018 data from the Department of Health.

State health officials said a number of factors contributed to the decline, including increased availability of Naloxone, better education for prescribers and use of the state’s prescription monitoring program.

The Legislature approved a plan in 2019 requiring opioid manufacturers to pay registration fees to the state, which will go toward prevention, law enforcement and treatment of opioid addiction. 

Overall, Minnesota’s overdose death rate has remained below the national average and below the rates of some of its Midwestern neighbors. In 2017, there were 7.8 opioid overdose deaths per 100,000 Minnesota residents, half the national rate.

Minnesota’s opioid overdose death rate half that of the U.S.

In 2017, there were 7.8 opioid overdose deaths per 100,000 residents in Minnesota, compared to 14.6 deaths per 100,000 residents nationally, according to the National Institute on Drug Abuse.

Planalp said researchers can’t definitively explain it, though the reasons are likely numerous and complex. He said heroin and synthetics like fentanyl tend to be correlated with geography because of drug trafficking patterns, while states with high prescription opioid death rates are scattered throughout the country.

On the whole, Minnesotans are a relatively healthy bunch. The state has one of the nation’s highest life expectancies and a low infant mortality rate. 

“Although Minnesota’s opioid overdose death rates are lower than the U.S. average, opioids are a problem in Minnesota,” Planalp said. 

As with many other issues — including education and economic well being — Minnesotans from communities of color experience worse outcomes when it comes to the opioid epidemic than the state as a whole. 

Farley said the state’s overall death rate tends to conceal significant and persistent racial disparities in the opioid epidemic’s impact, linked to longstanding inequities in access to health care for people of color.

“That average masks the meaningful numbers that we had one of the highest overdose rates for American Indians and also black Minnesotans” in the nation compared to other states who reported demographic data, he said.

Significant racial disparities persist in Minnesota opioid epidemic

The state’s racial disparities in opioid overdose death rates were the worst in the country in 2015, according to the Minnesota Department of Health. The chart shows the number of deaths per 100,000 residents.

As in the rest of the country, Minnesota has seen synthetic opioid overdoses surpass prescription narcotics. Nearly 60% of the 331 deaths in 2018 were caused by synthetic opioid overdoses, up from about 44% the year before, the preliminary data show.

Sam Robertson, MDH prevention specialist, said the department is raising awareness that drugs like heroin or cocaine may contain fentanyl without the users’ knowledge, as well as emphasizing the importance of carrying Naloxone.

Young people struggle to find ‘appropriate’ treatment

Access to comprehensive treatment for opioid addiction also remains an issue in Minnesota — especially for people between 18 and 25, the age group with the highest rates of prescription opioid and heroin abuse, said Gonzalez, chair of the American Academy of Pediatrics Committee on Substance Use and Prevention.

Young adults have lower retention rates in treatment than older age groups, Gonzalez said. He and a team of five experts rely on medication and therapy in their work with the younger demographic.

Gonzalez said he’s aware of just one other team targeting opioid use disorder among youth in the United States. Most clinics treat people of all ages, which he said is important for the broadest possible impact but means young people often don’t receive developmentally appropriate care.

“We have a lot of diversity not only in ethnicity and race, but also in who’s married, who has kids, who has some educational experience, who’s working three jobs … and what the family construct is.”

Minnesotans outside the Twin Cities have it especially hard. Gonzalez said some of the 60 young adults working with his team drive hours to the clinic. He’d like to expand their reach in the near future.

“People taking on these small pieces of the puzzle together are going to be critically important to make a network so that … young people don’t fall through and don’t end up dying,” Gonzalez said. “Once a kid is able to get some stability, there’s no reason they can’t then get on with their lives and go on to do all sorts of things.”