A middle-aged man smokes crack cocaine in Rhode Island. The state had the fourth-highest rate of cocaine-related overdose deaths in the country in 2022.
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In Pawtucket, RI, near a store advertising “free” cell phones, JR sat on an empty back staircase and showed a reporter how he tried to avoid an overdose while smoking crack cocaine.
(NPR is identifying him by his initials because he fears being arrested for illegal drug use.)
It had been hours since his last hit, and the talkative middle-aged man’s hands moved quickly. In one hand he held a glass pipe. In the other, a chunk of cocaine the size of a lentil.
Or at least JR hopes it’s cocaine, pure cocaine — uncontaminated by anything. Fentanyl druga powerful opioid linked to nearly 80% of overdose deaths in Rhode Island in 2022.
He lit up to “test” his supply. If it smelled “sweet like cigars,” he said, it meant his cocaine was laced with “fetty” or fentanyl. He put the pipe to his lips and took a tentative drag. “Not sweet,” he said, reassuringly.
But the “method” he devised offers only false—and dangerous—assurance. The reality is that it’s impossible to tell for sure whether a drug contains fentanyl by taste or smell. And a mistake could be fatal.
“Some people may believe they can smell it. [fentanyl] or taste it, or see it…but that’s not a scientific experiment,” he said Dr. Josiah “Jody” Richan addiction expert and researcher who teaches at Brown University. “People are going to die today because they bought some cocaine that they didn’t know had fentanyl in it.’’
Combining stimulants like cocaine and methamphetamine with fentanyl – a synthetic opioid 50 times more potent more powerful than heroin – is fueling what experts call an “opioid epidemic.”fourth wave.” This mix poses major challenges to overdose reduction efforts, as many stimulant users are unaware that they are at risk of ingesting opioids and therefore do not take overdose prevention measures.
The only way to know if cocaine or other stimulants contain fentanyl is to use drug testing tools like fentanyl test strips – the best method for Harm reduction now accepted by federal health officials to combat overdose deaths. Fentanyl test strips cost just $2 for a two-pack online, but many frontline organizations also offer them for free.
A test kit is used to detect the powerful opioid fentanyl in a sample of cocaine.
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In the United States, the first wave of the long and devastating opioid epidemic began with the misuse of prescription painkillers (early 2000s); the second wave involved the rise in heroin use, beginning around 2010.
The third wave began when powerful synthetic opioids like fentanyl began appearing around 2015.
Now, experts are seeing the fourth phase of this deadly epidemic. Nationwide, illicit stimulants mixed with fentanyl are the most common drugs found in fentanyl-related overdoses, according to a learn published in 2023 in the scientific journal Addiction.
The stimulant in the fatal mixture is usually cocaine in the Northeast, and methamphetamine in the West and much of the Midwest and South.
“The number one cause of overdose deaths in the United States is the combination of fentanyl and stimulants,” he said. Joseph Friedmana researcher at UCLA and lead author of the study.
“Black and African Americans are being hit hardest by this crisis, especially in the Northeast.”
Factors causing multiple drug overdose
It’s unclear whether the latest trend in polypharmacy is intentional or unintentional. A recent study from Millennium Health found that most people who use fentanyl do so sometimes intentionally and sometimes unintentionally.
People often use stimulants to get a boost during a rapid withdrawal from fentanyl, Friedman said. And using cocaine or meth with heroin is a high-risk activity, known as play speed ballhas been around for decades.
Other factors include manufacturers adding cheap synthetic opioids to stimulants to stretch supply or dealers mixing up bags of the drugs.
But researchers say in Rhode Island, many people still think they’re using pure cocaine or crack — a misconception that can be deadly.
Stimulant users unprepared for fentanyl’s prevalence
“People who use stimulants, not those who intentionally use opioids, are unprepared to deal with opioid overdose…because they don’t perceive themselves to be at risk,” he said. Jaclyn White Hughtoan epidemiologist at Brown University and lead researcher on a new study, unpublished research called Stimulant-Related Overdose Prevention.
Researchers surveyed more than 260 people in Rhode Island and Massachusetts who used drugs, including some who manufactured and distributed stimulants such as cocaine.
More than 60% of people interviewed in Rhode Island had purchased or used a stimulant that they later found contained fentanyl.
In 2022, Rhode Island has the fourth Highest price of cocaine-related drug overdose deaths in 2022, behind DC, Delaware and Vermont, according to the US Centers for Disease Control and Prevention (CDC).
People who do not regularly use opioids have a lower tolerance, putting them at higher risk of overdose.
And many of the people interviewed in this study also used drugs alone, so if they overdosed, they may not be detected until it was too late.
Jennifer Dubois, a single mother whose 19-year-old son, Clifton, died in 2020 of a drug overdose. The counterfeit Adderall he took contained the powerful opioid fentanyl.
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Dubois is a single mother of two black sons. Her older son, Clifton, has struggled with addiction since he was 14, she said. Clifton has also been diagnosed with ADHD and a mood disorder.
Clifton had just enrolled in a rehabilitation program in March 2020 when the pandemic hit, Dubois said.
Because of the lockdown at the rehab center, Clifton was upset that he couldn’t visit his mother. “He said, ‘If I can’t see my mom, I can’t do treatment,'” Dubois recalled. “And I begged him to ‘keep going.'”
But soon after, Clifton left the rehab program. He showed up at her door. “And I just cried,” she said.
Dubois’ youngest son was living at home. Dubois didn’t want Clifton to use drugs in front of her brother. So she gave Clifton an ultimatum: “If you want to stay home, you have to stay away from drugs.”
Clifton went to stay with family friends, first in Atlanta, and then in Woonsocket, an old mill town with Rhode Island Highest price death by drug overdose
In August 2020, Clifton overdosed but regained consciousness. Dubois said Clifton later confided that he had snorted cocaine in his car with a friend.
Hospital records show his test results were positive for fentanyl.
“He was really scared,” Dubois said. After the overdose, he tried to “get off cocaine and hard drugs,” she said. “But he took the pills.”
Eight months later, on April 17, 2021, Clifton was found unconscious in a family member’s bedroom.
The night before, Clifton had purchased counterfeit Adderall, according to the police report. What he didn’t know was that the Adderall had been laced with fentanyl.
“He thought that by staying away from street drugs… and just taking pills, he would get better,” Dubois said. “I really believe that Cliff thought he was taking something safe.”
A memorial plaque was posted in downtown Woonsocket, RI in 2023 by friends of Jennifer Dubois. The plaque features her 19-year-old son, Clifton, who died in 2020 of a drug overdose.
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The opioid epidemic is increasing mortality rates among older African Americans (ages 55-64) and more recently Latinx people, according to a learn recently published in American Journal of Psychiatry.
But Joseph Friedman, a researcher at UC San Diego and author of the study, said focusing solely on whether fentanyl was present was too simplistic.
For years, hospitals have safely used medical-grade fentanyl for postoperative pain because the drug’s potency is tightly regulated.
“It’s not the potency of fentanyl that’s dangerous,” he said. “It’s the fact that the potency fluctuates wildly in the illicit market.”
Studies of street drugs show that in illicit drugs, fentanyl concentrations can vary from 1% to 70%, he said.
“Imagine you order a mixed drink in a bar and it has anywhere from one to 70 shots of alcohol, and the only way to know is to start drinking it… There would be a lot of deaths from alcohol overdose,” Friedman said.
He said drug testing technology can provide a rough estimate of fentanyl levels, but to get an accurate measurement, the drugs need to be sent to a lab.
Fentanyl drug test strips provides a low-cost solution to prevent overdoses by detecting the presence of fentanyl, regardless of strength, in cocaine and other illicit drugs.
In Rhode Island, testing kits are available for free from harm reduction groups like Weber/Renew Project.
But the tests only work if people use them – and then don’t use the drugs if they test positive for fentanyl. And not enough people use stimulants for them to work.
This story comes from NPR’s health reporting partnership with Public radio And KFF Health News.
