Confronting the Rise in Stimulant Use in America

It seems like the 1980s are making a comeback—along with some unfortunate aspects like cocaine.

While deaths from opioid overdoses are thankfully decreasing, there’s been a troubling rise in stimulant use and related fatalities, especially with cocaine and methamphetamine. For instance, there were 10,375 deaths from cocaine overdoses in 2016, but that number skyrocketed to 29,449 by 2023. Similarly, meth fatalities jumped from 9,438 in 2017 to 33,283 in 2023. The preferred drug can differ depending on the region in the U.S. For example, cocaine remains prevalent in the Northeast, while meth use dominates in other areas.

This increase in stimulant use amid a decline in opioid-related deaths serves as a reminder that drug use doesn’t stop; it evolves. It’s simplistic to label someone strictly as a heroin or cocaine user. Nowadays, individuals often use multiple substances for various reasons, which can, unfortunately, heighten their risk of death. Additionally, the drugs in circulation are increasingly complex and often synthetic, which raises the chances that users are unaware of what they are actually consuming.

The changes in drug use patterns present significant challenges for public health. After years of concentrating on the opioid crisis, which centered around prescription pills, heroin, and fentanyl, we now find ourselves in a position where we lack effective interventions for cocaine and meth addiction. Unlike the frameworks established for opioids—where medications like methadone and buprenorphine help facilitate treatment—no similar options exist for stimulants.

Keith Humphreys, a psychiatry and behavioral sciences professor at Stanford, notes, “There is no medication for cocaine or methamphetamine. Everything under the sun has been tested and nothing has worked.” This absence of effective medical treatments means that behavioral therapies tend to be confined to specialty clinics, not routinely available in primary care settings, which often serve as a user’s first point of contact with the health system. Moreover, recognizing the signs of stimulant abuse or overdose can be trickier compared to opioids.

If we wish to avert another drug crisis that echoes the scale of the opioid epidemic, there’s substantial work to be done. But there’s a path forward—employing the same foundational principles that led to lowered opioid-related deaths could be key.

Dr. Brian Hurley, a former president of the American Society of Addiction Medicine, points out that while the specific interventions may differ, fostering community ties and ensuring access to evidence-based treatments is crucial.

Shifting Dynamics in Drug Use

The narrative of America’s interaction with hard drugs has shifted over time. Following the post-Vietnam surge in heroin use, the ’80s saw cocaine and crack cocaine emerge dramatically, leading to tough responses during the Reagan administration. Meth began gaining traction in the ’90s, and as the 2000s rolled in, the focus shifted to prescription pain medications, which eventually birthed a new drug crisis, while cocaine and meth use had seemingly plateaued. For quite a while, opioids were the predominant concern.

Experts indicate that stimulants, particularly since the mid-2010s, have made a strong return, with meth becoming more potent due to increased cartel production. Notably, a concerning trend in recent overdose cases has been the uptick in incidents involving both stimulants and opioids.

Experts categorize the concurrent use of opioids, especially fentanyl, with stimulants like cocaine and meth into three categories:

• Unintentional co-use: Some users may believe they are consuming cocaine, only to encounter product laced with fentanyl—an especially dangerous mix, as even minute doses can lead to fatal outcomes, particularly for those without a tolerance.
• Intentional recreational co-use: Here, individuals consciously mix stimulants and opioids in pursuit of a particular high.
• Symptom management: This reflects a more complex reality where people intentionally use both types of drugs to manage their habits. For example, someone may use cocaine to counteract the sedative effects of fentanyl, or meth during opioid withdrawal to alleviate symptoms.

Regardless of motivation, using opioids and stimulants simultaneously complicates health outcomes, placing significant stress on the body. This back-and-forth between various conditions can escalate quickly, leading to serious complications over time.

Addressing Stimulant Abuse Effectively

The public health sector is working hard to adapt to this resurgence of stimulants. Currently, a successful treatment model is called contingency management, which rewards individuals for remaining drug-free—an approach that has shown effectiveness in clinical trials. Participants provide urine samples at clinics, where a clean result may earn them a gift card. California initiated a pilot program in 2021, successfully treating over 10,000 people and achieving better outcomes than traditional behavioral approaches.

Unfortunately, outside of states like Rhode Island and Vermont, funding and access to contingency management via Medicaid or private insurance remain quite limited. Some policymakers are skeptical about the efficacy of rewarding sobriety, which adds another layer of complexity in implementing effective systems.

As we push for scalability in contingency management, there’s also a pressing need to advance medication-assisted treatments. The current measurement of success tends to hinge on complete abstinence, but some experts argue that this perspective might be a bit narrow.

Karla Wagner, a behavioral scientist at the University of Nevada Reno, highlights, “The only benchmark for getting a treatment approved is whether people stop using for a sustained period at the end of the trial.” However, her research suggests that relevant medications can lead to meaningful improvements beyond mere drug cessation, such as reduced cravings and lower-risk behaviors.

“These outcomes can be really impactful and genuinely enhance quality of life,” she emphasizes.

In her view, a recent blog by the National Institute on Drug Abuse’s director advocating for broader evaluative measures was encouraging. Additionally, the American Society for Addiction Medicine has backed the off-label use of stimulant medications that demonstrate promise in addressing cocaine and meth addiction.

Understanding the Rise in Stimulant Use

Finding a rapid response solution similar to Narcan for cocaine and meth overdoses is a critical challenge in medical science. However, improving public awareness of stimulant overdose symptoms and appropriate responses can play a significant role in preventing tragic outcomes.

Experts recommend being vigilant for signs such as:

• Heart palpitations
• Increased body temperature
• Erratic behavior, including hallucinations
• Sensitivity to light and sound

If someone shows these symptoms, there are ways to assist. Pia Marcus of OnPoint NYC suggests, if you’re familiar with the individual, calming them down can help. Creating a tranquil environment by dimming lights or reducing noise may also be beneficial. Additionally, physically cooling the individual with ice can help.

“Soothe them to assist in grounding their sensation of reality,” Marcus advises. “It’s crucial to stabilize their emotional state.”

While there’s potential to provide effective support in community settings, should these tactics fail, or if the individual appears to be having a cardiac incident, seeking emergency medical help is essential.

The decline in opioid deaths stands as a testament to the potential impact of public health strategies. Now is the opportune moment to apply similar strategies to curb the burgeoning crisis surrounding cocaine and meth before it escalates further.