Opioid crisis? It’s more complex than that: Study shows fatalities usually involve multiple drugs

Rick Bowmer/Associated Press/file/Associated Press

It may be time to stop talking about the “opioid crisis.”

Not because the crisis is over — some five people a day continue to die of overdoses in Massachusetts.

But a new analysis reveals that opioids are far from the only problem: The vast majority of people who died of opioid-related overdoses in the state had taken other drugs along with heroin and fentanyl, including stimulants like cocaine and methamphetamine. Only 17 percent had taken opioids and nothing else.

“At this point we’re not dealing with an opioid overdose crisis, we’re dealing with polysubstance use. . . . It really is a drug-overdose crisis,” said Dr. Joshua A. Barocas, an infectious disease specialist at Boston Medical Center and lead author of the study, published last month in the journal Drug and Alcohol Dependence.

While providers in the addiction field have long been aware of the rise of cocaine and methamphetamine, the study provides data to back up the anecdotes. And it points to social and demographic factors, such as race and homelessness, that affect who is most at risk.

The research also raises the possibility that a significant proportion of those who died weren’t even addicted to opioids; rather they were probably cocaine users who inadvertently ingested cocaine contaminated with fentanyl. Black people, who are at higher risk for cocaine use, were twice as likely as whites to die with both opioids and stimulants.

The findings suggest, Barocas said, that the state needs to broaden its focus, considering all kinds of addiction and the social factors that drive it.

Dr. Monica Bharel, the state’s public health commissioner, agrees about the importance of social factors but believes “opioid crisis” is an appropriate term — because the presence of illicit fentanyl, an opioid, is driving the death rate.

For example, while deaths involving stimulants have increased by 25 percent each year since 2010, the majority of those deaths involved opioids as well, usually fentanyl, according to a recent state data brief.

“The more we learn about the evolution of the epidemic, the more it challenges us to think about the way we address it,” Bharel said. “We think about addiction as a medical disease, but it’s really impacted by the social determinants of health, just like any other disease. We have to address the social determinants.”

Dr. Joji Suzuki, director of addiction psychiatry at Brigham and Women’s Hospital, who was not involved in the research, called it “an important study.”

“This study confirms what we’ve been seeing — that stimulants are playing an increasing role in overdose deaths,” Suzuki said in an e-mail to the Globe.

“This likely represents intentional mixing of the drugs . . . as well as inadvertent exposure to opioids among those who use cocaine. . . . It does reinforce the need to ensure individuals who use stimulants are getting support and treatment.”

Along with other researchers from Boston Medical Center’s Grayken Center for Addiction, Brown University, and the Massachusetts Department of Public Health, Barocas delved into a data “ warehouse” unique to Massachusetts that links information about individuals from several sources, such as insurance claims and medical examiner’s reports.

They studied the 2,244 people who died of opioid-related overdoses in 2014 and 2015 for whom the medical examiner was able to identify the drugs in their bodies.

Although the numbers are four years old, Barocas said there was no reason to think the trends have changed since 2015. If anything, they may have accelerated, he said. When he asks the drug users he treats for infections what they’re injecting, “well over half” say they use heroin or fentanyl plus methamphetamine or cocaine, he said.

The study found that less than 20 percent of those who died had taken opioids alone. Thirty-six percent took opioids along with stimulants, chiefly cocaine but also amphetamines. Forty-seven percent took other substances with their opioids, including alcohol, sedatives, and marijuana.

Non-Hispanic blacks, people older than 25, people who had recently been homeless, and people with mental illness all were more likely to have used multiple substances.

Barocas theorizes that people in those categories have less mobility and “cannot control their own drug supply; they get what’s coming to them.”

Just over half of those who died had suffered from a mental illness: depression, bipolar disorder, or schizophrenia. (Other mental illnesses were not included in the data.)

Only 7 percent lived in rural areas, contradicting the image of the opioid epidemic as a rural phenomenon.

Opioids slow down the nervous system, and stimulants speed it up. Drug users have long enjoyed getting both “downer” and “upper” effects simultaneously, Barocas said. “It’s the same reason people drink Red Bull and vodka,” he said.

But with illicit drugs, this practice multiplies the hazards. Stimulants don’t last as long as heroin, so there’s a tendency to inject more often, raising the overdose risk.

Opioids can kill by slowing breathing, but stimulants don’t counteract that effect because they don’t act on the brain’s respiratory center, Barocas said. Meanwhile, cocaine and amphetamines harm the cardiovascular system and can lead to heart attacks and strokes.

“The next steps are to develop better programs and better treatments for stimulant use disorder,” Barocas said.

More importantly, he added, “We need to shift the paradigm of health care. Until we address housing disparities . . . until we increase access to public transportation and mental health treatment, we’re just going to be chasing our tails.”