None of the nine wealthy 20-somethings who were rushed to Manhattan emergency rooms by ambulance one night in November 2019 meant to use opioids. They all thought they were using cocaine, until seven of them passed out within minutes of the first bump.
All of them needed hits of naloxone, the overdose reversal drug, on the way to the hospital. Two were so far gone that they needed three.
The partiers were part of five groups who didn’t know each other, but several had the same contact’s number in their phones, suggesting that a tainted batch of coke was indeed floating around Midtown and Lower Manhattan that night. Blood tests indicated that the cocaine was tainted with fentanyl, the synthetic opioid blamed for most of the country’s overdose deaths, according to a case report published in December in the American Journal of Emergency Medicine.
This incident happened in “the before times,” the month before COVID-19 appeared, triggering worldwide isolation and disrupting social and party life for millions of people in the United States. Now, as the availability of vaccines turned lockdown into “hot vax summer,” experts around the country warn that social drug users are facing a new normal where the drug supply, including cocaine and meth, is tainted with fentanyl, raising the risk of overdoses and death.
“Today, pretty much every cocaine and meth user in Ohio knows there’s a risk of fentanyl in their drug,” said Dennis Cauchon, the president of Harm Reduction Ohio, which has been tracking fentanyl-contaminated cocaine since 2017. “Two years ago, this wasn’t the case. Today, it is.”
Overdose deaths soared nearly 30 percent from 2019 to more than 93,000 in 2020, according to preliminary CDC data released in July. This sharp increase is driven by fentanyl. According to the White House, fentanyl and its analogs figured in 62 percent of deaths.
Researchers believe the COVID-19 pandemic is partly to blame for the spike in drug-overdose deaths. Socially-distanced drug users used alone or used an unfamiliar supply, which translated to unexpected overdoses with nobody around to administer life-saving Narcan. But lurking in the data is another disturbing trend: “accidental” or “unintentional” opioid overdoses befalling people who never intended to use opioids.
The ‘fourth wave’
Whether accidental or intentional, overdosing on fentanyl-contaminated stimulants is common enough for researchers to declare it the overdose crisis’ “fourth wave,” following the flood of prescription pills that segued into heroin and then synthetic opioids. Owing to limitations in data, this phenomenon is very difficult for researchers to quantify—and even harder to quantify in real time.
But experts in harm reduction, clinical researchers, and public health professionals who spoke to VICE News agreed that the drug market is absolutely flooded with fentanyl—which means a constant, impossible-to-quantify risk of fentanyl contaminating cocaine, meth, ecstasy, and other drugs.
Warnings of fentanyl-tainted cocaine spread around New York City earlier this summer, prompting the usual responses from harm-reduction specialists. Start slowly. Don’t use alone. Carry naloxone. Use test strips to detect potential contamination.
What no one can do is put a solid figure on how risky it is to use cocaine or how widespread the contamination problem is, other than issue vague warnings that fentanyl is more prevalent than ever—and if you use drugs, you’re “more likely to encounter fentanyl than ever before,” as the New York City Health Department put it in an April press release.
Data on overdose deaths is assembled at the usual speed for academic research, which in the “real world” is painfully slow. As of August 9, New York City’s Health Department had yet to finalize its overdose-deaths total for 2020; the most recent update was issued in April. (Asked to provide fresh data, a spokeswoman for the department pointed VICE News to the April release.)
Too often, data is culled from postmortem toxicology or medical examiners’ reports, which take months to finalize and give no indication if the user meant to pair a stimulant with an opioid—a speedball—or if they were accidentally or unwittingly taking fentanyl. And data from law-enforcement seizures doesn’t mean much for what’s actually in the drugs users are taking.
“There is no good database on supply. We are operating blindly.”
“There is no good database on supply,” as Dr. Daniel Ciccarone, a professor and a researcher at the University of California, San Francisco, told VICE News. “We are operating blindly.”
And well-off, “social” drug users are the drug users researchers know the least about. They’re less likely to access services. Since the Manhattan partiers all survived, they were still alive to tell doctors they weren’t opiate users and that they never meant to use opioids. That meant they became rare sources of extremely valuable information.
“That’s why it jumped out: None of them intended to use opioids or fentanyl at all,” said Dr. Philip DiSalvo, a physician and former fellow in medical toxicology at the NYC Poison Control Center, who was the report’s lead author. “They were just looking for cocaine.”
According to research on New York City’s pandemic party scene led by New York University researcher Dr. Joseph Palamar, during the COVID-19 pandemic, with fewer parties and less partying, most drug users used less. However, a small minority reported using more—and the richer and older they were, the likelier they were to overindulge, during the pandemic.
And now, with clubs and bars reopening and music venues selling tickets even as a Delta-variant winter looms, “social drug use is expected to increase,” Palamar said in an interview. “Rolling on ecstasy at home alone isn't very satisfactory,” he said. “People on this drug need to be around people, as it is a very social drug.”
Certain cocaine and meth users did up their drug intakes during the pandemic. Some may continue to use more now. But while Palamar knows enough to criticize reporting that dismissed the risk of fentanyl-contaminated cocaine as low, he still doesn’t know enough to quantify the risk.
“We need a lot more research focusing on fentanyl adulteration of stimulants,” he said. “To my knowledge, most use of stimulants plus fentanyl is intentional, not accidental. But accidental exposure does happen.”
UCSF’s Ciccarone says he has still-unpublished data showing that the probability of fentanyl-tainted meth, for example, “is quite low.”
But Ciccarone can’t figure out from the data if there’s enough fentanyl to be toxic. He also can’t tell enough to issue warnings, to cocaine users in Columbus but not to meth users in Cincinnati. Things change too quickly and data is gleaned too slowly.
How much fentanyl?
It’s not that there aren’t plenty of numbers; it’s just that they really don’t mean much.
In Ohio, fentanyl was in 18.8 percent of the cocaine seized by law enforcement so far in 2021, according to data that Cauchon, the president of Harm Reduction Ohio, presented in May at the Case Western Reserve medical school in Cleveland.
In early June, San Francisco police seized 16 pounds of fentanyl—or enough “to wipe out San Francisco's population four times over,” as police Chief Bill Scott said in an unhelpfully hyperbolic statement. This does not mean that there’s about a 1-in-5 chance of overdosing on opioids after a bump in Cleveland. Nor does it mean all the coke in San Francisco will kill you. It just means that there’s lots of fentanyl out there—and it’s very hard to say where until it’s too late.
“It will be a while before we know what happened in 2021,” said Dr. Sheila Vakharia, a harm-reduction specialist and the deputy director of research and academic engagement at the Drug Policy Alliance.
“It stands to reason that since parties and festivals have resumed,” drug use will resume, she said, noting that disruptions in supply and use mean “your old dealers/hookups maybe not in the game anymore, people’s tolerances may be down, and they may be using differently sourced drugs than what they were used to.”
For front-line workers, the best strategies to prevent accidental opioid overdoses among party-drug users are too radical for lawmakers to embrace anytime soon.
Mary Howe runs a needle exchange program at the Homeless Youth Alliance in San Francisco’s Haight Ashbury neighborhood. There, in 2018, three men in their 30s all overdosed and died on the same night, after either freebasing cocaine or smoking methamphetamine contaminated with fentanyl.
“People regularly think they are using a certain drug when, quite often—surprise—there is fentanyl in it.”
“The majority of people I know that are dying of overdose are dying because the drugs are so inconsistent,” she said. “People regularly think they are using a certain drug when, quite often—surprise—there is fentanyl in it.”
Harm-reduction centers have responded to this by providing test strips—which might detect fentanyl or carfentanil but not one of the many analogs that depress breathing in the same way but have a different chemical structure.
In Howe’s view, if society were serious about flattening the curve of the overdose crisis’ fourth wave, there would be a guaranteed clean drug supply available—maybe something along the lines of lab-tested commercial cannabis. Something close to legal heroin and cocaine, in other words.
“Imagine if people actually had informed decision-making, like you're in a store buying an item and you look at the packaging and it tells you everything and in what quantity is contained in said item,” she said. “I want to see people enabled to be informed about what they are putting in their bodies.”
Until then, everyone will grope around in the dark, occasionally tripping over unseen threats straight into an overdose. It’s Russian roulette, with an unknown number of bullets in a revolver with an unknown number of chambers in the cylinder.
“People don’t like the unknown, but this is an unknown, and we have to accept that,” said DiSalvo, who called the risk to social drug users “qualitative risk assessment, rather than quantitative.” That is, you know it’s there, but you’ll never know how much of “it” there is. And for now, that’s as good as it’s going to get.
“It’s probably rare to get seriously ill or die from a fentanyl-contaminated batch of cocaine, but it absolutely happens, at every level,” he added. “People have to know it’s a risk.”