PROVIDENCE – First, the good news. The most recent overdose fatality data for our state is encouraging. As of this writing, there is a 7 percent decrease in the number of confirmed deaths for the first six months of 2023, compared to the first six months of 2022 [214 versus 231, according to the data compiled by the R.I. Department of Health. If this trend of a decreased rate holds, it means that Rhode Island will see its first reduction of our state’s overdose death rate in five years, since 2019.

Translated, the many millions of dollars invested, the who-knows-how-many hours of thought and effort, the diligent work of the front-line workers such as Counselors, Peer Recovery Specialists, Community Health Workers, and Outreach Workers have saved many, many lives.

Further, the ongoing work of the Governor’s Opioid Overdose Prevention and Intervention Task Force has provided us with a sound framework and strategies. We are systemically managing the overdose epidemic, thanks to the large, dynamic, informed, and dedicated group of community and state workers that continue to struggle to contain and manage what has become an intractable nightmare for at least the last 10 years.

The deadly nightmare keeps morphing.
We continue to live the daily nightmare of the loss of our family members, our friends, and our co-workers.

Part of the good news is that our management of the overdose epidemic is saving lives. The bad news is that because that management is the focus of our resources and effort, we have not yet focused on the most salient aspect of the overdose crises.

We are no longer in an opioid crisis; it’s a poisoning crisis, according to Dan Ciccarone, a University of California at San Francisco professor and the principal investigator of the “NIDA Heroin in Transition” study.

Sam Quinones, who has researched and written extensively about the opioid overdose epidemic, echoed that same conclusion: “To anyone paying attention to the overdose crisis in the United States, it should be clear that the country no longer faces only a drug problem. It faces a national poisoning. The supplies of fentanyl and methamphetamine here have surpassed anything previously imaginable.”

Quinones described what he called the new reality: The “unrelenting supply of synthetic drugs such as fentanyl and methamphetamine has created a new reality for drug use across the nation. These synthetic drugs changed everything.”

The problem, Quinones continued: “There is nothing about drug smuggling, profit, use, addiction, treatment, etc. – there is nothing that remains the same. It’s all been changed by these two drugs.” [Emphasis added.]

Tracking the changes  
The changes in illicit drug supply – the move in the market from opioids to more potent synthetics and stimulants – have been well documented but not necessarily heard.

In May of 2018, the National Drug Early Warning System quoted psychiatrist Dr. Robert DuPont M.D, [president of the Institute for Behavior and Health], who said that the opioid crisis is now about synthetics and polydrug use, and that the global illegal market is switching from agricultural products to purely synthetic drugs.

As a result of that change, “Illegal drug users… are able to buy more drugs, at higher potency and lower prices, with more convenient delivery than ever before,” DuPont said,

Those synthetics include fentanyl, the dangers of which as an adulterant to other illicit drugs, including counterfeit pills, are well-known to us now.

The national data continues to be staggering:

•    On average, one person dies of a fentanyl overdose in the United States every seven minutes.
•   The emergence of fentanyl has coincided with the rise of overdose deaths involving stimulants [e.g., cocaine] and psychostimulants [e.g., methamphetamine] since 2017.
•   The Centers for Disease Control and Prevention [CDC] report that stimulants were present in 42 percent of overdose deaths that involved opioids, according to the 2023 preliminary data.
•   The number of people killed by fentanyl has increased by 94 percent since 2019 – it kills more people than automobile accidents, or suicides, or gunshots.

Unlike with heroin, there are few long-term fentanyl users.

Children of the opioid generation  
The effects on our youth, the children of the “opioid generation,” has become frightening. The emergence of fentanyl has increased the number of youth [ages 10-19] in the national fentanyl-involved overdose fatality rate to the point that it is now the third-leading cause of death in that age group. And, of the young people that died, only 1 in 10 had a history of substance use disorder [SUD] treatment, and only 1 in 7 had a prior overdose.

“Fentanyl and counterfeit pills are really complicating our efforts to stop these overdoses,” said Dr. Andrew Terranella, the CDC’s expert on adolescent addiction medicine and overdose prevention. “Many times, these kids are overdosing without any awareness of what they’re taking.”

In a recent NPR report, Dr. Nora Volkow, MD, director of the National Institute on Drug Abuse at the National Institutes of Health, said that teenagers rarely use fentanyl intentionally. What they do use, she continued, are ADHD medications [usually Adderall], opioids for pain relief [e.g., Percocet], and sedatives [usually Xanax] to help with sleep or relieve anxiety. She said that many of the illicit pills are basically fentanyl.

The Drug Enforcement Agency [DEA] reports that 4 out of every 10 counterfeit pills contain a potentially lethal dose of fentanyl. In 2021, the DEA seized 20 million fake pills [more than the combined total for 2019 and 2020].

And, the synthetic illicit drugs are easy to find. Not surprisingly, social media, platforms such as Instagram and Snapchat, have emerged as a market place to sell illicit drugs. 

“Social media have become a superhighway of drugs,” said Jon DeLena, deputy special agent in charge of the federal DEA’s New England field division. “If you have a smartphone and a social media account, a drug trafficker can find you.”

According to the Journal of the American Medical Association, there were about 1,550 pediatric deaths from fentanyl in 2021 – 30 times more than in 2013, when the wave of overdose deaths involving synthetic opioids first started in the US.

Illicit contamination  
And worse, as detailed in the 2022 ConvergenceRI story, “Entering the Fourth Wave of the overdose epidemic,” was the discovery by TestRI researchers at Brown University of more than 50 additives to the state’s illicit drug supply. [See link to story below.]

Many of those additives were either themselves toxic [Phenacetin, Levamisol] or would have a potentiating effect for overdose [Alprazalom, Gabapentin, as well as any of the more than 200 fentanyl analogs or derivatives].

Two years later, there is much more bad news. As the government has acted to try and reduce the production and proliferation of fentanyl-related drugs, new, dangerous threats are emerging. 

A 2022 study published in the Journal of Analytical Toxicology characterized the “post-fentanyl-analogue era” as a gradual shift toward a new generation of non-fentanyl-related synthetic opioids. The study argued: “Their dynamic and unpredictable recrudescence on the recreational opioid market has further deepened the complexity and diversity of the novel psychoactive substances [NPS] opioid landscape.”

•      For example, in 2019, the drug Isonitnitazene quickly became so popular that it was designated as a DEA Schedule I [it can be up to 800 times more potent than morphine].

As a result, multiple nitazene analogues started appearing as a means to circumvent scheduling. Within a year, isonitazene was replaced by brophine; when brophine was scheduled, it was replaced by metonitazene.

The life cycle of these NPS opioids is typically three months to a year, depending on how long it takes for government to respond with controls, at which point a new [legal] alternative is formulated.

We can expect this kind of adaptative innovation to continue. As Quinones wrote in his book, The Least of Us, “Organic chemistry can be endlessly manipulated.”

Avoiding the nightmare so far  
So far, Rhode Island has managed to avoid the high-impact methamphetamine nightmare. However, just as fentanyl finally infiltrated the West Coast drug supply a couple of years ago, it seems inevitable that we will continue to see a local increase in methamphetamine use as it moves east [In September of  2022 in Cumberland, R.I., the DEA seized 666,000 counterfeit Adderall pills that contained meth].

Tommy Joyce, director of the East Bay Recovery Center, said in a 2021 interview in The Providence Journal:  “It’s (meth) always been on my radar. We were fortunate that it’s never really affected Rhode Island until now.”

The story quoted Joyce as wondering “whether Rhode Island is equipped to deal with a surge in methamphetamine abuse,” given the apparent lack of effective and available treatment.

Marta Sokolowska, the deputy director for Substance Use and Behavioral Health at the FDA’s Center for Drug Evaluation and Research, said: “The truth is, we really don’t have a good answer at this point as to why it’s so challenging to develop these treatments.”

Not your grandfather’s meth  
The illicit stream of methamphetamine is a different product than the traditional meth. The meth that was dominant from the 1980s to the early 2000s was ephedrine-based and easy to produce. A tweak in the ephedrine molecule yielded meth. It was experienced as a euphoric; it was used as a social drug, a party drug.

But in the early 2000s, the U.S.and Mexico cracked down on the amount of imported ephedrine [the U.S. crackdown also eliminated the practice of buying large amounts of Sudafed at the drug store].

The always adaptable, illicit drug industry reverted to the pre-1980s California biker gangs practice of meth manufacture using the P2P method. That method uses combinations of legal, cheap, and toxic chemicals that include cyanide, lye, sulfuric and hydrochloric acid, and nitro styrene.

According to Quinones’ reporting, the result has been the establishment of hundreds of labs producing tons of P2P meth. He reports that it is so easy and economical to make that there is now a “massive unregulated free market,” a “pulsing ecosystem,” that in the U.S. includes meat-plant workers, money-wiring services, restaurants, farm foremen, safe houses, mechanics and used-car lots.

Quinones cited a former New Mexico police narcotics supervisor who did meth workshops for New England police: “The use of meth didn’t hit New England until 2019 with the supplies of  [P2P] meth… The supply creates the demand – New England is an example of that.”

A December 2023 story in The New York Times described P2P meth as “a monster super meth.” The toxic chemicals have made it sinister, what Tommy Joyce characterized as “an evil drug.”

Cause and effect  
In contrast to cocaine, the much longer meth half-life results in a longer duration of effect, and that leads to much higher concentrations in the synapses, which can be toxic to nerve terminals.

Quinones reported that: “The symptoms are always the same – violent paranoia, agonizing hallucinations, isolation, rotted and abscessed teeth, uncontrollable limbs, massive memory loss, jumbled speech, and, almost always, homelessness. It creates people who are ‘all but untreatable by usual methods of drug rehabilitation.’”

It’s inevitable that new meth will lead to a range of long-term psychological and medical complications, further stressing our already stressed public health system. It’s also clear that we are experiencing the changes cited by Quinones: nothing remains the same.

What we do know is that overdoses occur when people don’t know what they are taking, or how much. It's not only existing users who are in more danger by the contaminated drug supply, but new users and people who have returned to use. The only predictability to the illicit drug supply is that it’s contaminated, and it’s deadly.

Supply now drives demand  
The traditional economic model of demand driving supply has been turned upside down – in the sophisticated and innovative drug industry model, supply drives demand. It’s a twist on The Voice  in the movie “Field of Dreams” – “If you build it, he will come.”

• There was no high demand for opioid pain medication until the Big Pharm cartel convinced doctors that pain was the ‘fifth vital sign’ and relentlessly pushed Oxycontin as a ‘non-addictive’ pain medication.
• There was no demand for fentanyl until traffickers learned that it was much easier and cheaper to produce and distribute than heroin.
• There was no demand for P2P meth in the East, until it became so easy and economical to make.

We are so aware of the daily time, effort, and resources required to simply work to manage the symptoms of the decades-long addiction epidemic. We are too aware of the adverse effects of burnout, compassion fatigue, and both direct and secondary trauma that our front-line workers continue to experience every day. We must find the collective energy and will to explicitly acknowledge that today’s primary driver of overdose deaths is the toxic drug supply. We must collectively realize and acknowledge the radical changes in the old familiar landscape.

We have not been able to successfully interdict, prohibit, convict, incarcerate, treat, or recover our way around our opioid addiction epidemic in the last 40 years. The question is: How can those same strategies stop the flow of the new toxic and always evolving torrent of drugs, when “there is nothing that remains the same?”

Ian Knowles is a person in long-term recovery.

Editor’s Note: In PART Two, Ian Knowles will discuss methods to disrupt the deadly drug supply.