High Wire is Maia Szalavitz’s reported opinion column on drugs and drug policy.
Way back in the 1980s, when I was injecting drugs, the speedball—a shot combining cocaine and heroin—was popularly known as the ultimate high. Zooming up on the coke with the steep swoop down cushioned by heroin seemed, well, perfect. That made the dangerous mix my drug of choice.
Nowadays, those sorts of cocktails are sometimes taken sequentially rather than in a single injection. That may be in part because stimulants mixed with opioids—often called “goofballs” when methamphetamine is used instead of cocaine—are increasingly sought for more pragmatic reasons: people taking drugs need that mix to fight off the effects of more powerful opioids.
It might seem like taking a sedative opioid with a pick-me-up drug like coke or meth would reduce overdose risk, because some effects might cancel each other out. In fact, these mixes are more deadly than taking opioids alone, though less so than mixing drugs that both have sedative effects, like benzodiazepines and opioids.
Part of what’s driving people to ignore the risks is that in much of the country, drugs sold as heroin either consist exclusively of or are contaminated with fentanyl, part of an opioid class that can be from 50 to literally thousands of times stronger than heroin itself. Even when this drug’s notorious potency doesn’t result in overdose, it still often causes intense sedation. That’s leading people to seek stimulants in order to simply stay conscious when they get high, experts and users said—a new pattern of DIY cocktail drug use with ominous health implications amid an already-deadly opioid crisis.
“I think there is a synergistic relationship between the saturation of fentanyl and stimulant use among opioid users,” said Jon Zibbell, a senior public health analyst at the research nonprofit RTI International who has spoken with dozens of people who take drugs in Massachusetts, Ohio, West Virginia, North Carolina, Indiana, and Kentucky.
In 2011, fentanyl and related drugs were identified in about 1,600 overdose deaths nationwide. But in 2018, provisional figures from the CDC suggest these substances may have killed over 30,000 people. As of 2016, fentanyl was the drug most commonly linked to overdoses in America.
At the same time, cocaine and methamphetamine overdoses are also skyrocketing—and these deaths typically involve at least one opioid as well. For example, 41 percent of cocaine overdoses also included fentanyl in 2016. And the more recent data shows the number of overdose deaths involving cocaine is equal to the number involving heroin, even exceeding that for prescription opioids.
“It may be an adaptation to fentanyl,” Dan Ciccarone, professor of family and community medicine at the University of California San Francisco, said of the fresh burst of interest in stimulants. “I think that’s a good hypothesis.”
While the modern opioid crisis has largely been depicted as a white problem, people of color are widely impacted, and resurgent speedball use could hit their communities especially hard. “We know that the epidemic has been whitewashed,” Zibbell said.
Law enforcement, treatment, and prevention specialists have blamed the rise of overdose deaths on fentanyl contamination in the cocaine and methamphetamine supply, which has occurred in some instances. But researchers suggest many of these deaths are likely due to speedballs or goofballs given that post-mortem analysis cannot determine whether the person deliberately or inadvertently took both drugs.
While heroin has long been known for its depressant effects—there’s a reason its high is known as “nodding out’—fentanyl is even more tranquilizing. (In hospitals, it’s used for anesthesia.) For some, blotting out the world entirely might be a feature rather than a bug. But most people with addiction need to spend at least some time awake, at the very least because they need to obtain more drugs.
“In a way, I needed it because otherwise I kept falling asleep and couldn’t work,” said Michael, a 38-year-old Utah man now in treatment who requested anonymity to describe how he used meth in addition to heroin.
Michael’s girlfriend had introduced him to heroin several years earlier; he worked repairing cars to supply both of them. He began taking meth after he found himself falling asleep at the wheel while trying to get to work. “I was spending an ungodly amount of money on drugs,” he recalled.
Diagnosed with ADHD as a child, Michael also had a legitimate prescription for Adderall, he said, but that wasn’t enough. “I had to keep doing meth to stay awake, otherwise I was just sitting there nodding out.”
And as his addiction got worse, he lost both his girlfriend and his home. Unfortunately, that meant he had yet more reasons to continue taking meth: Being homeless means being vulnerable, as any possessions, cash, or drugs you have are likely to be stolen if you are unconscious. And in the winter, Michael had to keep moving because, as he put it, “if you fall asleep, you might not wake up.”
Harm-reduction workers and researchers who are studying the epidemic see people like Michael every day. “I can say the speedball is back on the East Coast,” said Ciccarone, adding that on the West Coast and other areas where methamphetamine is more common than cocaine, goofballs predominate.
Ciccarone noted that many people who report using meth to balance out the sedation from opioids take the drugs at different times, rather than in the same injection. This is not the way people who prefer the combination high do it: The intensity of a speedball is traditionally related to how rapidly both effects are felt in sequence. (For some reason, even with simultaneous injection, the stimulant effect precedes the opioid, if only by a few seconds.)
Doing the drugs separately, however, allows the stimulant effect to be experienced when it is most needed—and also keeps it from interfering with desired sedation. “We’re seeing both,” said Zibbell. “Some use concurrently and some use sequentially.”
All of this adds up to a dangerous trend. Because the fentanyl high lasts for a much shorter time than heroin’s does, people are likely to inject more frequently. If they are adding a sequential stimulant shot, that’s an additional injection. And, since cocaine is especially short-acting and stimulants tend to create a rapid desire to inject again, users may find themselves falling into potentially fatal behavior.
Indeed, cocaine injection is particularly linked to the spread of blood-borne illness because its short high means that people will often inject as frequently as every 15 minutes until they run out.
If needles are shared, there is obviously the risk of HIV and hepatitis C. If the injection site isn’t properly sterilized, there is a risk of skin infections, abscesses, and systemic infections. “The literature shows that that is the case,” Zibell said. “The more you inject, the more susceptible you are.”
“We’re seeing loads of abscesses and infections,” said Louise Beale Vincent, HCV and drug user health coordinator at the North Carolina Harm Reduction Coalition, noting that when people are injecting so frequently, they are less likely to wash their hands or clean the injection site.
Their lives may also become less functional because more frequent injecting simply takes up time. It also means more hours spent seeking drugs. Frequent injection of cocaine or methamphetamine can also cause paranoia and psychosis, especially when people go for days without sleeping.
To make matters worse, there is no medication treatment available for stimulants, and so using both together can complicate the path to recovery. “You are adding all of the things that make it chaotic,” Vincent said.
In order to prevent the opioid crisis from doing even more damage, we need to better understand how the saturation of fentanyl is changing the way people take drugs. More injections and more drug mixing means more risk of disease and overdose, which makes the need for harm-reduction programs like needle exchanges and safe injection facilities even more acute.
It also once again demonstrates the futility of trying to stop drugs by cutting certain sources of supply. People who take drug mixes have always found alternatives when one ingredient is scarce. We need to stop chasing one drug after another, and keep the focus on saving lives.
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