Polysubstance Use and Stimulants: A Dangerous Fourth Wave in the Opioid Crisis

Health City

Over the past 20 years the opioid epidemic has washed over the country in waves. First came the arrival of OxyContin and the rapid spread of prescribed opioids in the late 1990s. Then came the migration from prescription pills to injected heroin. And finally, about five years ago, came fentanyl and a staggering rise in overdose deaths.

Each of these three overlapping waves was closely tied to a different form of opioid. Now, addiction experts talk of a cresting fourth wave in the epidemic: the widespread use of stimulants and other illicit drugs alongside opioids.


Jessie Gaeta, MD, the medical director of the Boston Health Care for the Homeless Program, says that many of the homeless patients she sees who have severe OUD have habitually layered opioids with up to four sedatives — benzodiazepines, gabapentin, clonidine, and promethazine — in order to "check out of the toxic environment around them."

But now methamphetamine is increasingly being added to this cocktail, which Gaeta first described in a 2016 piece for Health Affairs. "Methamphetamines have arrived on the scene locally, in droves," she says. "I'm not saying it wasn't here before, but we'd rarely see it on toxicology screens or hear people telling us about it. But now it's almost the norm."

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