The brightly-colored trend lines on the projected chart rise and fall until suddenly, in 2015, they all begin to spike simultaneously, reaching new heights. This chart summarizes epidemics of cocaine, methamphetamine, and prescription stimulants over the past 50 years, and more stimulants are being misused than ever before. This, combined with the opioid crisis, is something new. As epidemiologist Jim Hall, Ph.D., noted at the recent National Cocaine, Meth, and Stimulant Summit, "We are no longer in an opioid crisis, we are in an addiction crisis."
The Stimulant Summit was held in November in Fort Lauderdale, the first of what will be an annual event. Plenaries offered a wide variety of material for a broad group of attendees, including Drug Enforcement Administration and other law enforcement officials, as well as mental health and substance abuse professionals seeking strategies to address the devastating impact of stimulant misuse. Clarity about dangerous trends emerged throughout the conference. For example, more than ever before, individuals are simultaneously abusing both stimulants and opioids. Many people not only switch to heroin when their prescription opioids are no longer available, but also use cocaine and meth. Young adults, among whom there is an epidemic of prescription stimulant abuse, are also turning to other drugs such as cocaine and meth. And this super-epidemic is intensified because these drugs are stronger, cheaper, and more lethal due to the addition of deadly fentanyl and the even more dangerous carfentanil.
The stimulant epidemic is as deadly as that of opioids, although it impacts different populations. Men who have sex with men (MSM), for example, are using meth and other drugs such as GHB/GBL in chemsex, the simultaneous use of drugs and sexual behavior. Chemsex in Black and Latinx communities of MSM is now driving the HIV epidemic. Cocaine overdose rates among black men rival those of opioid overdoses among white men. Heterosexual women, particularly in economically deprived areas, are using meth to a greater extent than ever before, resulting in a dramatic increase in children being separated from their mothers. Costs of treating meth-related complications for those who are incarcerated, including the infamous "meth mouth," threaten to break state budgets. Students seeking to "get smart" before exams misuse stimulants, along with many wanting to control their weight, find energy for daily routines, and simply stay awake for long drives or tedious work.
Increasing injection drug use is also taking a toll. The Centers for Disease Control and Prevention has identified several hundred counties similar to the one in Indiana where injection of heroin created an HIV outbreak at rates like those of some of the more hard-hit countries in sub-Saharan Africa. And from 2004 to 2014, among those aged 18 to 29, rates of hepatitis C increased by a staggering 400% as opioid injection drug use [[jumped by 622% [www.cdc.gov/pwid/index.html]]. Among those aged 30 to 39, the rate of hepatitis C increase was nearly as much, at 325%.
Simulants, including meth, are not a new class of drugs. Meth was first formulated in the 19th century and then crystalized in 1919 in Japan. During the 1880s, cocaine was a popular cure-all for many ailments and was available over the counter. In 1933, Smith, Kline, and French introduced the Benzedrine Inhaler, also available over the counter, which contained 325 mg of pure methamphetamine. Other brands of stimulants, including Benzedrine and Dexedrine, soon emerged and, in World War II, all sides were using amphetamines for energy, wakefulness, and aggression. Kamikaze pilots bolstered their sense of invincibility and courage by taking meth, and the journals of Hitler's personal physician revealed he was injected with meth several times a day. After the war, Japan was left with a huge stockpile of methamphetamine, which created a devastating meth epidemic in that country in the 1950s. Meth spread throughout Southeast Asia -- where it remains a major concern -- and, in the U.S., the pharmaceutical industry continued to develop new forms of stimulants. In the 1970s, stimulants were moved to Schedule II (high potential for abuse), approved only for narcolepsy and (what is now called) attention deficit hyperactivity disorder (ADHD). In the 1980s, new forms became available, such as MDA, a stimulant that created a mellow high, which was ultimately replaced with MDMA, (ecstasy). Throughout the decades, the purity of stimulants continued to rise, especially when the Mexican drug cartels began to monopolize manufacture and distribution after 2000.
Since then, many worrisome trends have taken shape. Since the 1980s, prescriptions for stimulants like dextroamphetamine-amphetamine (Adderall) and methylphenidate (Ritalin) have quintupled, and in 2018, federal drug agents seized 10 times more meth than a decade ago. A number of other synthetic designer stimulants have been introduced and caused great harm, such as the flakka outbreak several years ago in South Florida. The High Intensity Drug Trafficking Area program (HIDTA) keeps track of such trends around the country and has documented an increase in cocaine seizures from 30,000 kg in 2013 to more than 160,000 kg in 2018, and an increase in cocaine deaths from 4,000 in 2011 to 15,000 in 2017. While these deaths all involved cocaine, most individuals had other drugs, including fentanyl, on board. In Philadelphia alone, overdose deaths involving cocaine and fentanyl increased from 1% of overdoses in 2011 to 32% in 2017.
At the Stimulant Summit, Mark Gold, M.D., one of the most highly regarded clinical researchers on stimulants, presented a plenary about new research on the physiological impact of stimulants. He reported that meth binges create an insult to the brain that is the equivalent of a football injury and results in brain trauma. Meth also creates changes in microglia (a type of cell in the brain) that are not reversible, something that is not true for other drugs.
Stimulants work by hijacking the brain's reward circuitry, the mechanism by which we receive little bursts of dopamine and other neurotransmitters as a result of activities that help us survive as a species, such as eating food, creating a sense of belonging or cooperation, and orgasm. These so-called natural rewards quickly lose their appeal with stimulant use, which resets the reward system to release dopamine only when there is much more stimulation from drugs and/or other behaviors such as sex. With stimulant addiction, the threshold at which one can experience pleasure is raised so that normal life activities pale by comparison and are unrewarding. As tolerance builds, greater quantities of the drug (or behavior) are required to achieve the same effect, significantly heightening the risk of overdose. Alarmingly, Gold believes that 30% of overdose deaths are actually suicides.
Unlike opioids, for which there are drugs that can reduce cravings, such as medication-assisted treatment, there are no such compounds for stimulants, either to reverse psychoactive effects or to minimize cravings, although studies are underway that indicate a potential benefit of some drugs for this purpose. Although still rare in the U.S., harm reduction approaches such as needle exchange, education, and safe injecting areas are proven to be effective.
The clinical treatment for stimulants is a long and complicated process. Consistent use, especially of meth, creates physiological changes in the brain that cause sustained depression, anhedonia (the inability to experience pleasure), and a powerful set of triggers and cravings that fuel frequent relapses. There are almost always co-occurring psychiatric conditions such as depression, anxiety, and psychosis, including extreme paranoia, that can persist well into abstinence. Meth numbs painful emotions and soothes intolerance for boredom or lack of stimulation. Treatment must recognize this, noting that concentration will be impaired, sometimes for months, and underlying issues such as shame must be addressed. In this era of unprecedented societal loneliness, it is important to note that the most critical factor predicting recovery from stimulant misuse is social connection.
We are at a cultural moment when we are experiencing simultaneous epidemics of various drugs that threaten the health and well-being of the nation and its people. The epidemic takes various forms among different populations. This requires multiple approaches for understanding the epidemiology among various populations, the risk for HIV and hepatitis C, and specific drug effects. This year's National Cocaine, Meth, and Stimulant Summit, the first of what will be an ongoing annual meeting, was a critical component in the solution for this dangerous epidemic.