Unveiling Parallels: Exploring the Shared Lessons of the Opioid and Stimulant Epidemics
"You medical people will have more lives to answer for in the other world than even we generals." -Napoleon Bonaparte
Imagine this: a highly addictive drug comes to market as a prescription. Representatives from the drug maker infiltrate physician offices, touting the drug as safe and effective. The drug reps are beautiful. They provide free fancy dinners, free vacations, and LOTS of free samples.
The first spark is lit. Physicians prescribe… and prescribe… and prescribe. Americans get addicted and die by the thousands. Horrified, physicians stop prescribing. But it’s too late. Millions of Americans are now addicted. And they are desperate.
Seeing a business opportunity, cartels flood the market with illicit forms of the same drug to meet the skyrocketing demand. They alter the drug to make it more addictive and more deadly. Americans buy. And many more die. The wildfire, now far beyond the original controlled burn lit by the American medical establishment, rages out of control.
You yawn. You’re thinking “Lauren. I’ve already seen Dopesick, Painkiller, Heroin, Do No Harm, and Pain Hustlers. I know the story of the opioid epidemic.” But hold on. This isn’t that rerun. This is also the story of the stimulant epidemic, unfolding before our eyes in real time.
The stories have chilling similarities. Just replace “Oxycontin” with “Adderall,” and replace “Heroin/Fentanyl” with “Methamphetamine” and it’s almost the same story. We are so distracted watching the opioid wildfire raging out of control that we don’t see the same stimulant blaze slowly gathering strength in the distance.
To understand how closely the emerging stimulant epidemic mirrors the opioid epidemic, let’s go back in time and review the opioid story. It’s a fascinating one.
The opioid epidemic unfolded in four waves. The first wave began in the mid to late 1990s. At that time, opioid overdose deaths started occurring with natural and semi-synthetic prescription opioids like OxyContin and Vicodin. These prescriptions came from largely well-meaning but ill-informed physicians. These providers were surrounded by drug reps preaching the gospel of “Pain as the Fifth Vital Sign.”
I went through medical school from 2005-2009. Our curriculum did not have any material on opioid prescribing or opioid safety. I had a vague hunch that opioids might be addictive. This was based solely on watching my favorite TV show at the time, House, which portrayed the brilliant Vicodin popping Dr. Gregory House (played by Hugh Laurie).
So when I first started working evening shifts in the ED during my fourth year of medical school and first year of residency, I naively refilled many scripts for patients coming through at night who had “run out” of their Oxycontin. There sure is a lot of pain in Charleston, South Carolina, I thought. People must be really sick here, I concluded. Little did I know how right I was, in a very wrong way.
Me at Med School Graduation as a newly minted doc: full of energy and naivity
The second wave of the opioid epidemic began in 2010, with rapid increases in overdose deaths involving heroin. Heroin replaced prescription opioids as doctors began to understand the dangers of opioids and prescriptions became harder to get.
The third wave of the opioid epidemic began in 2013, with significant increases in overdose deaths involving fentanyl. Both heroin and fentanyl are illicit synthetic opioids made and mass distributed almost exclusively by two cartels located in southwestern Mexico.
Fentanyl is up to 50 times stronger than heroin and 100 times stronger than morphine. The amount that fits on the head of a pen is deadly. The raw ingredients for fentanyl come from China. Then our industrious friends down south at the Juarez and Sinaloa cartels make fentanyl from these raw ingredients and send it out on mass distribution paths throughout the US. With fentanyl, the cartels had significantly “improved” their product. It was much more addictive, and much, much more deadly.
By this time, I had seen enough overdose deaths in residency to know that opioids were deceptively dangerous. As I started my Addiction fellowship in 2013, I was no longer prescribing Oxycontin. I was prescribing Suboxone to treat the epidemic I had helped spread only a few years earlier.
The fourth wave of the opioid epidemic started in 2019, with the rise of methamphetamine (meth) and cocaine laced fentanyl overdose deaths. In 2024, much of the current fentanyl supply is also laced with cocaine or methamphetamine. Sometimes dubbed the “twin friends,” the cartels had refined their product once again. It’s crafty on their part. Fentanyl is a depressant or a “downer” with calming/sedating effects, while cocaine and meth are powerful stimulants or “uppers” that increase energy, anxiety, and heart rate.
The cartels’ blueprint for this latest tweak was an early 2000s version of a downer/upper combo containing heroin and cocaine- commonly called a “Speedball.” Speedballs often give stronger effects than either drug alone due to drug synergy. When compared with single ingredient drugs, speedballs are also more addictive and more dangerous, with higher rates of fatal heart attacks and strokes due to the stimulant components. Some folks have nicknamed today’s fentanyl/meth/cocaine combo “super speedballs.” In 2023, the use of methamphetamine among people who also use fentanyl reached a record high, while prescription opioid use reached a historic low. Notable deaths attributed to Speedballs and Super Speedballs include John Belushi, Chris Farley, Philip Seymour Hoffman, and River Phoenix.
Finally, some experts are beginning to describe an emerging Fifth Wave of the Opioid Epidemic characterized by Xylazine laced Fentanyl. Xylazine-the newest star of the show- was on the cover of the ASAM March/April 2024 magazine issue. It’s getting a lot of attention. Philadelphia is the Xylazine epicenter of the United States. As a very powerful depressant, Xylazine deserves its own article for you to fully appreciate and understand its intricacies, and why it too is so dangerous (stay tuned!). But suffice it to say, it’s no bueno. If you suffer from opioid use disorder and are still struggling with substances, don’t stop in Philly.
Why is it important to understand the history of the opioid epidemic? Because it is the story of the stimulant epidemic. Prescription stimulants for ADHD like Ritalin and Adderall first hit the market in the late 1980s/early 1990s. But they did not gain rapid prescribing traction until the late 90s.
According to DEA production data, after 1995, medical consumption of stimulants more than quintupled. Like the opioid epidemic, as legal availability increased, so did illicit use. By 2005, some 600,000 Americans abused prescription stimulants nonmedically per month. When I graduated from college in 2005, illicit Adderall use was so common and universally accepted, it was nicknamed “Vitamin A.”
When a drug is treated not only as a legal medication but a virtually harmless one, it is very difficult to make a convincing case that the same drug can also be very harmful. Accordingly, prescribed stimulants continued to increase in the market, with a 70% increase from 2011 to 2021.
With the Public Health Emergency (PHE) declaration in March of 2020, restrictions requiring in-person appointments for controlled substances (including stimulants) were lifted. Suddenly, Adderall prescriptions were attainable with a ten-to-fifteen-minute on-line visit. Stimulant prescriptions surged. We had poured gasoline on the flame. Now we had a full-blown fire. From 2020-2021 alone, rates of stimulant prescribing rose between 10-19%, with the largest increases seen in women. By mid 2021, there were widespread stimulant shortages throughout the country, with many areas going days or weeks with almost no stimulant availability. The stimulant genie was fully out of the bottle.
By early 2023, the DEA had noticed the trend. They were concerned. In a well-meaning but not fully thought-out decision, they ended the PHE exemption for fully telehealth appointments for controlled substance initiation in May of 2023. There was immediate wide-spread backlash and panic from patients and providers alike. Many clinicians did not have the infrastructure in place to return to in-person appointments overnight. Responding to the panic, the DEA quickly retracted the May 2023 in-person requirement, extending the existing COVID telehealth exemptions until December 2024.
In early 2023, the DEA launched several widely publicized investigations into online ADHD companies, including the online prescriber Cerebral. At the same time, commercial pharmacies like Walgreens and CVS began requiring the patient to live within 50 miles of their prescriber to pick up a stimulant prescription. For the first time, the legal supply of stimulants slowly began to contract, while the illicit supply of methamphetamine laced fentanyl expanded. Sound familiar?
When you boil it down, both epidemics essentially involve increased legal prescribing of an addictive medication, followed by decreased prescribing after abuse is evident, and culminating in a more potent, more dangerous replacement version infiltrating illicit supply. Addiction experts sardonically call it the “Suburban slide:” Middle-class America starts with a prescription medication and inevitably “slide” into illicit use once the prescribers realize the full consequences and stop prescribing.
Oxycontin→Heroine→Fentanyl
Adderall→Methamphetamine→Methamphetamine laced Fentanyl
How could we let this happen twice? And what can we learn? First, we need to support our prescribers sooner with objective, comprehensive, real-time training and education on addictive medications as soon as they emerge on the market. We need to have a pro-active versus reactive approach to providing our clinicians and pharmacists with objective facts and best practice protocols for controlled substance prescribing before the damage is done- not after. A fire hydrant doesn’t do much good once the entire house is on fire.
Second, we should prohibit drug rep access to prescribers. Drug reps are not physicians. They do not provide objective facts or data. They are paid by the drug company to promote and sell their drug. Period. Their central motivation is profit, not patient safety. We prescribers need to make medical decisions based on the latest evidence-based medicine and CDC guidance, not by the rep who provided the most free lunches.
Finally, when it comes to the prescribing and dispensing of opioids, stimulants, or any other addictive controlled substance, we need specific, concrete, universally agreed upon protocols for prescriber and pharmacist reference. In the wake of millions of opioid overdose deaths, these recommendations now exist for opioids.
They don’t yet exist for stimulants. If you are diagnosed with ADHD tomorrow, your provider might write for a 5 mg dose prescription for Adderall or an 80 mg dose of Adderall. You might get a 7-day supply or a 60-day supply. You might be (correctly) counseled to take sparingly and only as needed, or to take it three times per day every day. Like opioids, we need centralized, specific, best practice prescribing guidelines for stimulants. Clinicians need these guidelines to make balanced decisions that consider both treatment efficacy and safety and diversion concerns. If I were the CDC, my guidelines would be the following:
All newly diagnosed ADHD patients must A) Fail two non-stimulant trials, each with a minimum duration of three months, prior to stimulant prescription and then B) If moving to new stimulant start, stay at doses of 5-15 mg of Adderall or Ritalin with dispensing quantity of no more than 14 tabs per month for the first three months and C) If medically necessary to increase dose after the first three months, keep dose at or below 20 mg daily unless additional extensive medical documentation justifies that the benefits of higher dose or quantity outweigh the increased risks of addiction and diversion. Additional guidelines should flesh out best practice guidelines for further dose and quantity increases, including monthly pill counts and urine drug screens for all. CDC and DEA- I’m available. Call me!
My hope is that we absorb meaningful, actionable lessons from the opioid and stimulant epidemics; lessons that we can use to prevent or reduce future harm. If it’s predictable, it’s preventable. The opioid and stimulant flames are now large wildfires. With talented American medical technology, ingenuity, and capitalism, there will soon be another. I dont know about you, but I’m ready to do things differently when it arrives.
Dr. Grawert is the Chief Medical Officer at Aware Recovery Care, which specialized in both in home and virtual addiction treatment. If you or someone you know is struggling with a substance use disorder, reach out today.
So true, accurate, timely, and important! Proud to be able to call you a (former) colleague!!