Molecular diagrams courtesy of PubChem.

By Taylor Knopf

In recent years, the street drug market has become increasingly polluted by additives. Number one among those is fentanyl, which is commonly added to heroin and now being added into other substances.

Fentanyl and its close relative, carfentanil, are synthetic opioids considered to be 100 to 10,000 times stronger than morphine. They are being found in many other drugs, a trend that accelerated during the coronavirus pandemic, according to harm reduction workers across the state.

Because certain fentanyl analogues are so potent, the smallest amounts can have major effects on users. These deadly blends have driven up the risk of overdose for people who use drugs.

Alicia Brunelli, an outreach worker with the North Carolina Harm Reduction Coalition said that because of this trend, she’s seen an increase in people using more than one drug at a time in Wake and Johnston counties. 

“When there’s fentanyl in the heroin supply, someone might want to counteract that and use a stimulant,” said Brunelli, who explained that users believe this protects them from the most harmful effects of a given substance.

Her organization, and others like it, have their collective ears to the ground among substance users. They offer clean needles and supplies to people using drugs so they don’t reuse or share needles, reducing the spread of HIV and hepatitis C infections. Many also provide free testing for these bloodborne infections and are major distributors of naloxone, an overdose reversal drug.

Brunelli has seen more people combining substances in a futile attempt to protect themselves as America’s drug crisis has shifted once again — from prescription opioids to heroin to fentanyl — to now, a combination of substances.

But the evidence — and increasing amounts of research — points to the fact that these upper/downer combinations don’t really provide any protection. With drugs that are more potent and with more people mixing them, more people are dying.

Stronger street drugs

Statistics show fentanyl is popping up in more substances, not just heroin. The Drug Enforcement Administration has reported a notable increase in seizures of methamphetamine and cocaine that include fentanyl.

Federal officials believe that some of the mixing of substances at the drug trafficking level may be unintentional, especially when dealers are selling more than one drug.

Synthetic opioids contributed to more than 36,000 overdose deaths nationwide in 2019, according to the National Center for Health Statistics. Deaths involving fentanyl made up more than half of the 2,320 drug-related deaths in 2019 in North Carolina.  

Alicia Brunelli, a NC Harm Reduction Coalition outreach worker, speaks at the virtual Opioid Misuse & Overdose Prevention Summit in May 2021 about polysubstance use among people she serves. Photo screenshot taken during her presentation

“People don’t want to die. The myth about drug users not caring about their health is B.S.,” Brunelli said during a presentation at the Opioid Misuse & Overdose Prevention Summit in May. “If you don’t want to have an overdose, and you know you’re using something very strong, you’re going to add a stimulant.”

Rise in cocaine and methamphetamine

The evidence bears Brunelli’s observation out, as an increasing number of Americans are dying from overdoses with more than one drug in their bodies. Aside from fentanyl, deaths from cocaine and methamphetamine – both stimulants – have become more common than deaths from heroin or prescription opioids alone. 

More than half of those stimulant deaths involve an added opioid, according to the National Institute for Health Care Management Foundation. 

North Carolina’s drug deaths have mirrored national trends. In 2019, 75 percent of all fatal drug overdoses in North Carolina involved more than one drug.

For decades people using drugs have attempted to “balance” their highs and lows by using stimulants combined with opioids. Stimulants, such as cocaine, speed up the body’s systems, producing an energy high. Opioids and depressants, such as Xanax, do the opposite by slowing the body’s systems down. In fact, opioids frequently cause death by slowing breathing to the point where users asphyxiate. 

In one research study, interviewers asked people using methamphetamine and prescription drugs — mainly benzodiazepines and opioids — about their patterns of using these substances together and or sequentially. Methamphetamine is known for keeping users awake for days, so many participants said they would use a Xanax or opioids to bring themselves down from a weekend high so that they could sleep and go to work the following day. One participant reported he used methamphetamine all week to get through long hours at work and would use prescription drugs to sleep and recharge on the weekends.

Some participants who were dependent on opioids for pain said they were often sleepy from the effects of the painkillers and would use methamphetamine to give them energy. Other participants told the researchers that using a stimulant and an opioid at the same time enhanced the effects of both drugs.

Data presented by Kristin Shiue, graduate research assistant at the UNC Injury Prevention Research Center, during the Opioid Misuse & Overdose Prevention Summit in May 2021.
Data presented by Kristin Shiue, graduate research assistant at the UNC Injury Prevention Research Center, during the Opioid Misuse & Overdose Prevention Summit in May 2021.

Polydrug use increases overdose risk

Using substances together at the same time can be dangerous and increases risk of overdose, said Mary Figgatt, a graduate research assistant at the Injury Prevention Research Center at UNC Chapel Hill. 

“For example, using opioids and alcohol at the same time can increase risk of respiratory depression in particular,” she said while presenting polysubstance use data at the opioid summit in May.

Figgatt reviewed nine years of death certificate data from fatal overdoses in North Carolina. Starting in 2016, she found a significant increase in polydrug use, particularly the combination of opioids and stimulants, mainly cocaine and methamphetamine. 

“To mitigate the opioid crisis, we can’t just focus on opioids,” she said. “We need to avoid a one- size-fits-all approach. And we need to educate people about safe polysubstance use practices, which combinations should be avoided and which combinations should be more spaced out in use.” 

Graph and data presented by Mary Figgatt, MPH Graduate Research Assistant UNC Injury Prevention Research Center, during the Opioid Misuse & Overdose Prevention Summit in May 2021.

Brunelli said harm reduction workers encourage people using drugs to make use of recently developed fentanyl test strips, which can detect the presence of the drug in another substance. She also reminds people using multiple substances to slow down, space out their use of different drugs and not to use drugs by themselves.

There is a number to call for those who do use alone: (800) 484-3731. Someone from the Never Use Alone initiative stays on the line with the person using drugs to make sure they are OK and call EMS if necessary.

Although health workers encourage safe drug practices and calling emergency services for help, some people using drugs are leery of dialing 911.

Unequal under the law

In North Carolina, there is limited legal protection under the Good Samaritan Law for people who call for help in the event of an overdose. 

But Brunelli said it is not applied equally. 

As written, the law gives the caller and overdose victim limited immunity for up to one gram of heroin or cocaine. The law doesn’t address other substances, such as methamphetamine, crack cocaine, fentanyl or alcohol for those under the legal drinking age. A bipartisan group of lawmakers tried to address some of these issues at the General Assembly this year, but the bill didn’t make a legislative deadline. The bill is unlikely to move during the rest of the biennial legislative work session.

“When we exclude substances, we are excluding the entire community that uses that substance,” Brunelli said. “It’s important to include all substances in our laws. If we’re going to protect one, we have to protect all of them.”

Expanding these protections under the law is also an important step toward racial equity, she said.  

“I’m not going to call the police if I’m using methamphetamine and my friend overdoses, especially if I’m a person of color,” Brunelli said. “I’m immediately going to feel like they’re going to blame me because that’s what the past has shown.”

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Taylor Knopf writes about mental health, including addiction and harm reduction. She lives in Raleigh and previously wrote for The News & Observer. Knopf has a bachelor's degree in sociology with a...

5 replies on “Three quarters of NC overdose deaths involve multiple drugs”

  1. Thank you for the article. The NC Medical Examiner’s Lab does not identify fentanyl on results. How do we account for the number of fentanyl overdoses in NC?

  2. The vast and overwhelming majority of people in North Carolina who die from drug overdoses are street drug abusers, not intractable pain patients who are legitimately prescribed opioids for chronic pain by their physicians, but you fail to state that in the article. That is precisely why many pain patients with unspeakable physical pain are often caught in the political crosshairs and unable to find a physician in NC who will treat their pain. From now on, please be a responsible journalist and draw the line between street drug abusers and intractable pain patients. Those two groups are and will always remain worlds apart. Thank you.

    1. At NC Health News, we’ve written several stories about the struggle pain patients face getting their prescriptions. Please check our archive for more on this. This story is entirely about the street drug market, as it states in the first line of the article.

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