A hidden epidemic of chronic disease — organ failure, leaky blood vessels, and “flesh eating” infections — might threaten cocaine and meth users in coming years because of increasing signs of dangerous adulterants in illicit drugs, analysts warn.
That’s worrisome because cocaine use is up 47% since its low point in 2011, with 2.2% of people over the age of 12 reporting they have snorted or smoked it in the last year. US cocaine and methamphetamine overdose deaths have also roughly tripled in the last five years, according to the CDC. (Methamphetamine overdoses killed 12,987 people last year, and cocaine overdoses killed another 15,699.)
The increases in deaths from these stimulant drugs have been obscured by an even larger number of deaths from opioids: mostly painkiller pills, heroin, or illicit fentanyl. More than 40,000 people died of opioid overdoses in 2018, a slight decline from the previous year, which remarkably led to the first decline in total US overdose deaths in 28 years.
“While the declining trend of overdose deaths is an encouraging sign, by no means have we declared victory against the epidemic or addiction,” Health and Human Services Secretary Alex Azar said in a statement addressing the drop of 5%, which still left a total of 67,774 people dead. “We also face other emerging threats, like concerning trends in cocaine and methamphetamine overdoses.”
Cocaine mixed with fentanyl, a potent opioid, is thought to be the major driver of the rise in stimulant deaths. The United Nations Office on Drugs and Crime blames record coca crops in Colombia and cheaper cocaine for a resultant stimulant-drug boom worldwide.
But the other emerging contributor is a hidden wave of toxic lab-made adulterants that are infiltrating the illicit drugs, suggest some experts in international narcotics.
“The danger is that we may not see a hidden epidemic starting up until it is too late,” Thom Browne of the Colombo Plan Secretariat, an intergovernmental Asia-Pacific organization, told BuzzFeed News. “We aren’t testing for these cutting agents, and chronic health problems [they cause] by their nature only appear years later.”
Browne’s claim, presented with new testing data at an April overdose meeting in Atlanta, challenges conventional wisdom about fentanyl’s outsize role in deaths from stimulant drugs. He suggests instead that toxic adulterants may be silently responsible for many more deaths than medical examiners realize, and may contribute to as many deaths as fentanyl overall.
Browne and colleagues point to adulterant-driven health crises among street drug users in South Africa and South America, which show up as outbreaks of organ failure and AIDS-like immune system collapses. They suggest that cutting agents in illicit drugs have turned markedly toxic, and are suggesting that many of the stimulant deaths in the US, too, could have those origins.
Experts such as Michael Lynch, medical director of the Pittsburgh Poison Center, told BuzzFeed News that better monitoring of adulterants was worthwhile, but said that fentanyl taken with stimulant drugs overall seemed a better explanation for mortality increases, similar to a CDC report released in May.
In Atlanta, Browne presented lab findings to show how toxic cutting agents are turning up in bewildering varieties and larger numbers than seen previously in illicit drugs. Samples of cocaine and heroin tested from three US states — Kentucky, Nevada, and Vermont — in 2016 and 2017 turned up with traces of numerous additives linked to erratic heartbeats, reduced immune system response, and organ failures, Browne and drug testing consultant David Martin of JMJ Technologies reported. The group also found signs of multiple toxic adulterants in North Carolina, Pennsylvania, and Texas, Browne told BuzzFeed News in July.
Warning signs about these adulterants have been around for a decade: The US Drug Enforcement Administration and public health researchers have been worrying about cocaine laced with levamisole, a veterinary drug for parasitic worms linked to severe infections, and phenacetin, a banned painkiller linked to cancer and kidney failure, since 2009. The DEA has suggested as far back as 2012 that levamisole is present in about 80% of the cocaine samples it tested, in concentrations as high as 10%.
The dangers of the adulterant are well-known. Levamisole in crack cocaine triggered headlines about “flesh eating” bacteria infections in the UK in 2016. The drug kills white blood cells, key parts of the immune system, leading to severe infections. Unlike older cutting agents, such as powdered milk added for bulk, or laxatives, these toxic additives generally boost or extend the high associated with drugs and are added to both stretch the supply of a drug and make it more sought after by people chasing a high.
What’s different now, suggested Browne, is that the chemistry knowledge of criminal cartels worldwide has increased just as trade globalization has delivered fentanyl, synthetic cannabinoids, and industrial methamphetamine to the US. This same trend also threatens to push adulterant concentrations to higher, more dangerous levels. Of the recent cocaine and heroin samples from Kentucky and Vermont, for example, 54% had nine or more toxic adulterants.
Some of the chemical know-how among traffickers has led to weird illicit drugs: Some “pink” cocaine made in Colombia is actually synthetic mescaline, a hallucinogen, while other pink cocaine is a mixture of cocaine, Ecstasy, and ketamine, an anesthetic used as a club drug. A translucent kind of “fish scales” cocaine sold in South America is actually a mixture of cocaine and phenacetin.
“You have to see the whole drug market moving toward synthetics,” he said. This is occurring as more people in the illicit drug market are using more drugs, so-called “polydrug” or multidrug use, in which they indiscriminately mix depressants — opioids like heroin — with stimulants like meth or cocaine, all of them adulterated in new ways, with unknown effects.
“Your dealer doesn’t really know what is in there,” Browne said. “Without more forensic drug testing, neither will we.”
Of course, there is always something new on the drug market, whether heroin sold as “gray death” or mescaline sold as pink cocaine, Lynch told BuzzFeed News, cautioning against overreacting.
“Fentanyl is such an overriding concern right now, due to overdose deaths,” that looking for the long-term signs of adulterants in cocaine that cause chronic illnesses will inevitably not loom as large a concern for understaffed and underbudgeted public health officials, Lynch said.
Warnings about adulterants also need to reach actual drug users to matter, epidemiologist Traci Green of the Boston Medical Center Injury Prevention Center told BuzzFeed News, not just law enforcement or public health types present at the April conference where Browne and Martin presented their results.
“Just ‘remove the labs! eradicate the cutting!’ isn't useful in the long run,” she added. Until the long-term health risks and ways to limit their exposure are understood on the street, the illicit drug market will just keep serving up more and more toxic adulterated drugs.
Browne agreed that fentanyl is a necessary priority for public health officials because of the epidemic of overdose deaths. However, contrary to suggestions by other observers that fentanyl explains most of the increase in stimulant deaths, his data suggests that adulterants may be an equally pervasive killer and, so, also warrant attention. “The other half of overdose deaths could be due to highly adulterated drugs,” he said. Meanwhile, chronic health problems caused by multiple adulterants might suddenly impose a burden on public health care systems in coming years.
From a global perspective, Browne said, not testing for toxic adulterants in the US looks shortsighted because they are known to have caused tremendous problems elsewhere in the world. “We have seen these health problems, primarily due do adulterated and impure cocaine, play out in South America over the last decade,” he said, with drug users suddenly turning up with severe infections or kidney and liver failure.
A 2017 Archives of Toxicology review, for example, found 233 case reports of severe infections tied to immune system collapse in chronic cocaine users, seen everywhere from Argentina to the US from 2010 to 2016. Separately, there have been more than 100 case reports of weakened blood vessels, another side effect of the adulterant, including at least one death in 2017 in North Carolina.
“The more ominous threat is the unknown interaction or synergistic effects of multiple toxic adulterants,” Browne added. Fentanyl demonstrates how synthetic drugs can go from obscure to tremendously dangerous in only a few years when they infiltrate illicit drug supplies, he pointed out. “Cutting with multiple adulterants is a fairly new phenomenon in the United States.”
The threat might be ignored because most US labs do not test for toxic adulterants. Crime labs look for illegal drugs like heroin or cocaine, not cattle dewormers, in order to enable criminal prosecutions. Hospitals, public health clinics, and coroners don’t, either, instead testing for the drugs that are primarily driving chemical dependencies — including heroin, cocaine, and meth — that lead to addiction.
So, Browne and Lynch agree, some of the money now coming into treating addiction and addressing the US overdose crisis should fill the gap where neither crime labs nor public health clinics test illicit drugs for adulterants.
“Police departments have this tremendous resource, seized drugs, that they can’t afford to test, and the samples are just sitting on lab shelves,” said Browne.
“Tests are expensive, but we know these things are dangerous. Shouldn’t we at least have some idea what is out there?” ●