STIM Spotlight: Concurrent Use of Stimulants, Opioids Defies Past Explanations

With some patterns of opioid use declining and stimulant use re-emerging in many communities, Daniel Ciccarone, MD, MPH, still would prefer that the field avoid identifying the next drug crisis by name of drug. At the Nov. 8-10 National Cocaine, Meth and Stimulant Summit in Miami, Ciccarone will argue that polysubstance use is rendering discussions of individual drug trends largely obsolete.

Addiction Professional interviewed Ciccarone, professor of family community medicine at the University of California, San Francisco and a leading authority on epidemiological trends in substance use. His summit session is titled “Of Speedballs and Goofballs: Stimulants and the 4th Wave of the Opioid Crisis,” but Ciccarone will make the case that we are in one of a long series of waves of a complex historical relationship with substances.

Editor's note: This interview has been edited for length and clarity.

What is the main takeaway from your current analysis of drug use trends?

If this wasn't completely true before, it's completely true now. We have to stop thinking about drugs as monolithic categories. Polydrug use is the norm. I'm still a little amazed by it, but when I go into the field I see that folks are using various drugs. This includes methamphetamine with an opioid, and that opioid is often fentanyl. I haven't done a field visit in the last six years that hasn't blown my mind. If we're trying to understand drug use, addiction, and treatment modalities, we should be thinking about polysubstance use.

Co-use of heroin and methamphetamine, often called “goofballing,” has been increasing in some communities. What do we know about why this is happening?

When I observed this the first time I went to West Virginia, I figured this was a “one-off,” because it's been a strange thing to do historically. But then I went back. The goofball is big. We have to ask ourselves, “How do we want to study a new drug phenomenon?”, because it deserves proper study. We need to ask all the key questions: who, why, how and when? I have more questions than answers at this point. Is this use a coping mechanism? A balancing act? Is it about improving functioning, where someone gets up with meth and goes to sleep with heroin? Does this fit neatly into our theories or do we need to come up with new theories? Some users seem to believe that there will be less harm from fentanyl if they co-use meth; that shouldn't be true.

Part of your conference presentation states, “The rise of stimulants shows a failure of public policy.” Can you explain?

There has been a singular focus on opioids, and more specifically a singular focus on pills. The blame has been placed on Big Pharma. Big Pharma caused something, but Big Pharma alone didn't cause it. “It” is a historically large problem. The methamphetamine epidemic has demonstrated this. Demand for drugs is a monster, continually being fed in ways that we're not predicting. Who predicted the resurgence of methamphetamine? No one, as far as I know. Meanwhile, the average patient has gotten much sicker while we've been handling the opioid crisis. Focusing on excess pill prescribing gives us something that is incomplete. This is a multi-headed monster.