The stories that Judith
Feinberg hears from people with substance use disorder are riddled with loss:
of jobs, opportunity, security, dignity. “People really are struggling to see
that they have a viable future,” Feinberg says. “Then you take a drug … and you
don’t care until you need the drug again.”

For years, that drug was very
likely an opioid. But Feinberg, a physician at West Virginia University School
of Medicine in Morgantown who studies infectious diseases and injection drug
use, recently has seen shifts in the addictive substances used. And it’s
occurring not just in West Virginia — which has the highest rate of drug overdose deaths in
the nation, at 51.5 deaths per 100,000 people — but across the country, the U.S. Centers for Disease
Control and Prevention reported January 30.

Fueled by a plentiful
supply, people have increasingly been turning to such stimulants as cocaine and
methamphetamine — so much so that the rates of overdose deaths for those drugs each
surpassed that of prescription opioids in 2018.

There’s a small bit of hope:
After two decades of rising numbers, around 3,000 fewer people overall died of a drug overdose in 2018 than in 2017. But with 67,367 deaths, 2018 ranks
as the second-worst year for drug overdoses in U.S. history. It’s too soon to
say whether the nudge downward is a blip or the start of a meaningful drop.

In part, that may depend
upon whether the rise in stimulant use over much of the last decade continues. In
2018, the rate of overdose deaths involving cocaine was 4.5 per 100,000, more
than triple what it was in 2012; for methamphetamine and similar drugs, the
rate jumped from 0.8 to 3.9 per 100,000 during that period. Each now surpasses
the death rate from prescription opioids, and cocaine’s rate is just shy of
heroin’s.

While the rates of overdose
deaths for prescription opioids and heroin each fell from 2017 to 2018,
suggesting some success in national efforts to address the opioid epidemic, deaths
from fentanyl and other synthetic opioids (SN: 5/1/18) continue to go
up, hitting 9.9 per 100,000 in 2018.

Opioids are depressants that
slow the body down and can halt breathing (SN: 3/29/18).
In contrast, stimulants like methamphetamine and cocaine ramp up the body,
increasing blood pressure, heart rate and body temperature. The drugs can also
make a person hallucinate or feel anxious or paranoid. An overdose can lead to
a fatal heart attack or stroke.

Although the outward effects
on a person’s body are different, stimulants and depressants both produce a
feeling of euphoria in the user. The drugs also lead to the release of dopamine,
a brain chemical that encourages a person to repeat pleasurable activities. “It’s
that dopamine release that is the hallmark of addiction,” Feinberg says.

Which drugs rise to the
forefront of the nation’s ongoing addiction crisis can change depending on
availability and cost. “We know that drug use comes in cycles,” says Jane
Maxwell, an epidemiologist at the University of Texas at Austin who tracks
trends in drug use. That cyclic nature, she says, partly depends upon what’s
easy to get.

Cocaine, for example, is
making a comeback, after being a major drug of abuse in the ’70s and ’80s. Colombia
is the primary source of cocaine in the United States. Since the country signed
a peace treaty with guerrilla fighters in 2016, coca plant cultivation and
cocaine production have risen, Maxwell says. That has increased the supply and
decreased the cost of the drug in the United States.

There’s also a large supply
of methamphetamine in the United States, but what’s widely available today is
more potent — with more potential for abuse — than in the past. The stimulant
used to be made from pseudoephedrine or ephedrine, ingredients in cold
medicines, but the United States limited over-the-counter sales of those drugs
in 2006. Today, meth is largely produced in Mexico in what’s known as the “P2P”
production method (Walter White turned to this method in later seasons of the
television series Breaking Bad). That
process creates a chemical form of meth that “has much more of a euphoric
effect,” Maxwell says.

Right now, the public health
toolkit against stimulant addiction lacks any pharmaceutical help, which
severely hampers the response. To counter the opioid epidemic, medications are
available, including buprenorphine to treat dependence on opioids and naloxone
to reverse an overdose. But no drugs have been approved to manage addiction to stimulants.

With the drugs that lead to
substance use disorders shifting over time, “all of this stuff is a moving
target,” Feinberg says. Focusing efforts on a particular drug doesn’t address
the larger societal problems that underlie substance use, she argues. “The real
question in my mind is, why do so many people in this country need to find
oblivion in some chemical experience?”