At the height of Philadelphia’s opioid crisis, a new challenge — an uptick in deaths and hospitalizations involving stimulants like cocaine and methamphetamine — started to emerge about two years ago, say physicians, outreach workers, and law enforcement officers.

Now that trickle has turned into a flood of cheap, pure methamphetamine. But it hasn’t replaced heroin and other opioids, depressants that remain the dominant drugs of choice. More people, intentionally or not, are mixing drugs that offer the opposite effects.

Fatal overdoses involving cocaine and methamphetamine rose dramatically between 2016 and 2017 in Philadelphia and stayed mostly stable in 2018. But opioids, especially the deadly synthetic fentanyl, were present in most of the stimulant-related overdoses in the last two years. Fentanyl was present in 65% of the 580 cocaine-related deaths in 2018 and 73% of the 75 meth-related deaths the same year.

At Temple University’s Episcopal Hospital — located in Kensington, the heart of the city’s opioid epidemic — about 55 patients a month test positive for meth, said James Graham, medical director of the crisis response center there. That’s a fraction of the 1,000 clients the center serves each month, he said, but it’s a 33% increase over the year before.

At Prevention Point, the Kensington-based public health organization, physicians have also seen more people in opioid treatment programs testing positive for methamphetamine.

Silvana Mazzella, Prevention Point’s associate executive director, said that five years ago, about 3% to 4% of drug tests in the center’s opioid treatment program would turn up positive for methamphetamine. Last year, it was 19%.

But very few clients at Prevention Point identify meth as their drug of choice, Mazzella said. “We’re talking a few hundred people a year that actually claim this,” she said. “There’s a discord between people saying it’s their drug of choice and people who get shocked when they test positive for it.”

Dangerous unpredictability

Over the last few years, a drug supply that was once generally cheap, pure, and consistent has become more unpredictable, with fentanyl largely replacing heroin and, occasionally, new cutting agents contaminating other drugs. That can be dangerous for people used to one drug but unwittingly or not consuming another. For instance, it could create a reaction the user is not expecting and doesn’t know how to handle.

A view of the corner of Kensington and Allegheny Avenues, an area known to be at the center of Philadelphia's heroin epidemic.
JESSICA GRIFFIN / Staff Photographer
A view of the corner of Kensington and Allegheny Avenues, an area known to be at the center of Philadelphia's heroin epidemic.

Similarly, Mazzella said, only about 5% of Prevention Point’s clients claim cocaine as their drug of choice. But several times a year, up to 41% of the treatment program’s drug tests are positive for cocaine, she said.

People who begin drug treatment for one substance, like opioids, sometimes start to use more of a different drug, she said. Others combine a downer, like an opioid, and a stimulant, like cocaine or meth. Drugs could also be getting combined or cross-contaminated without the users’ knowledge.

Some homeless opioid users have told Ben Cocchiaro, a physician at Prevention Point who works in the organization’s mobile buprenorphine program, that they seek out methamphetamine. They want to stay awake because they’re afraid of theft or violence.

“These are folks who don’t have a place to live, and they’re scared they’re going to be beaten up by someone if they fall asleep,” he said. “I also have plenty of folks who express surprise at testing positive — they’re trying to consume some other substance, and it’s being substituted with meth.”

Cheap and pure

Patrick Trainor, a spokesperson for the local branch of the U.S. Drug Enforcement Administration, said there is an abundance of cheap, “phenomenally pure” methamphetamine in the city, much of it manufactured and trafficked in from Mexico. There’s more supply in Philadelphia than demand for the drug, he said, and that drives down the price.

“For a long time, stimulant users were stimulant users and opioid users were opioid users, and never the twain shall meet,” he said. “Now you see a lot of people who do both.”

Mixing drugs is a statewide phenomenon, said Michael Lynch, medical director of the University of Pittsburgh’s Poison Center. National studies have reflected this: a 2018 study published in the Journal of Drug and Alcohol Dependency found that 34% of opioid users seeking drug treatment in 2017 had admitted using meth in the last month — an 82% increase from 2011.

People who use drugs in Kensington said they see the trend every day. “Meth was never heard of around here — it was like a Northeast, biker bar, suburbs thing. And it was expensive,” said Kristen Paris, 31, who has been in opioid addiction for years. “Things have really changed.”

Kristen Paris speaks with a reporter in Kensington about stimulant use in the area.
JESSICA GRIFFIN / Staff Photographer
Kristen Paris speaks with a reporter in Kensington about stimulant use in the area.

Paris has also recently turned to stimulants. She likes the heady rush of cocaine, but also uses it to “come up” from the powerful sedative effects of fentanyl-laced heroin. “You don’t want to go to sleep, because no one wants to have their stuff stolen,” she said. “You do cocaine, and you’re just trying to stay awake.”

Another woman, Amanda Dryden, said she began using meth about a year ago, but had been using heroin longer. Meth feels good and can ease the pain of heroin withdrawal, she said. Avoiding pain, not getting high, is uppermost for many long-term, heavily addicted opioid users, whose built-up resistance puts pleasure from the drug out of reach.

One woman who normally uses heroin and declined to give her name said she had tried meth and hated its effects. That makes her worry about contamination, especially since others have told her they’d unwittingly tested positive for methamphetamine.

“We still don’t have a full, complete understanding of stimulant use on the ground. There seem to be all kinds of mixed messages flying around,” said Kendra Viner, the opioid surveillance program manager for Philadelphia’s Public Health Department. “There definitely seems to be a disconnect between what people think they’re buying and what’s found in their toxicology if they die, or their drugs are tested. There are a lot of really dangerous cutting agents on the scene.”

Treating addiction for the two types of drugs is very different. Medications exist to help opioid users deal with cravings, while stimulant users are generally asked to focus more on behavior modifications, Lynch said.

In other ways, the addictions are similar.

“People who have a substance use disorder — it’s bigger than a single agent,” Lynch said. “We’re complicated beings psychologically. Whether [drug use] is genetic, environmental, [used for] coping, [rooted in] childhood trauma, or more likely a combination of those things, if it’s not being adequately treated, a substance use disorder fills a gap. And when something becomes cheap, pure, and available, the use of that will rise.”