The Fourth Wave of the Opioid Crisis: How Agencies Need to Respond to Overdoses with Fentanyl and Stimulants

In 1959, Janssen Pharmaceutica patented a new opioid, fentanyl, that would soon be used as an anesthetic in surgeries and an analgesic for general pain relief. What the company’s founder, Dr. Paul Janssen, likely did not realize at the time was the devastation fentanyl and stimulants would cause.

Polysubstance Use with Fentanyl and Stimulants: A Fatal Combination

Polysubstance use involving Janssen’s patented fentanyl has become today's biggest overdose threat, accounting for nearly two-thirds of the overdose deaths in 2021. Nearly 70 years after the original patent was granted, fentanyl is at the center of a crisis that has taken 645,000 lives between 1999 and 2021.

But it didn’t start with the polysubstance-related deaths we see today. It started with prescriptions.

The History of the Opioid Crisis

In 1991, doctors wrote around 76 million prescriptions for opioids. In 2011, that number was 219 million. The increase in these prescriptions was the start of the first wave of the opioid crisis, with a marked spike in 1999. These opioids included methadone, hydrocodone, and oxycodone as pain relievers, as well as benzodiazepines like Xanax, Valium, and Ativan for various other conditions. With the increase in prescriptions came an increase in opioid-connected overdoses and deaths.

In 2010, the second wave of the opioid crisis was marked by the flooding of the US market with Colombian and Mexican heroin. This opiate offered a more available, more potent, and less expensive alternative to prescriptions. But by 2013, heroin was no longer leading the statistics in overdose deaths. Fentanyl use would become the drug of choice, initiating the third wave of the opioid crisis.

The potency of fentanyl (50 to 100 times the strength of morphine) made it an inexpensive and powerful drug. But that potency led to sharp increases in overdoses starting in 2015. Between 2010 and 2015, polysubstance use involving fentanyl often included heroin, prescription opioids, alcohol, and benzodiazepines. But by 2021, the combination was almost exclusively fentanyl and stimulants, specifically cocaine and methamphetamine. And much of the fentanyl had moved from prescription sources to illicit manufacturing.

The Fourth Wave: Overdoses from Fentanyl and Stimulants

Today, fentanyl is the most prominent cause of overdose deaths in the US, accounting for 66% of the total overdose deaths in 2021. This is due in part to the prevalence of illicitly produced fentanyl in nearly all illicit drugs, often without the knowledge of the people using the drugs.

In 2010, fentanyl was tied to less than 10% of the 40,000 overdose deaths in the US, and less than 1% were due to polysubstance use with fentanyl and stimulants. In just 11 years, that percentage would grow to just over 32%—a 146.5% increase.

So what does it mean for treatment courts today?

Relapse Risks with Polysubstance Use

The pervasive presence of fentanyl, as well as its greater potency, has created public health concerns and challenges that didn’t exist in the first three waves of the crisis.

The risk of relapse with fentanyl and stimulants is significant, both in the struggles to overcome addiction and in the dangers of decreased tolerance to both substances. As drug users remain sober, the tolerance they had once built from years of use begins to stabilize. That return to normal brain chemistry balance is important, but it makes relapse far more dangerous.

And with potent drugs, including fentanyl and meth, even a single relapse could be fatal.

The Need for Better Intervention Strategies

With the increased threat of overdose-related fatalities from fentanyl and stimulant polysubstance use, past intervention strategies are not enough to provide safety and accountability for individuals struggling with their recovery process. And with additional threats like fentanyl-laced vapes, that accountability is even more important than before. Treatment courts need continuous accountability to help reduce the dangers connected to polysubstance relapse.

Continuous Accountability

More than anything, recovering addicts need accountability to keep their efforts on track. Relapse is a given in most recovery programs, but with the increased potency of drug combinations like fentanyl and meth or cocaine, participants in recovery courts need an extra level of supervision for their use patterns.

Increased staffing is seldom a viable solution, with the strain of the opioid crisis already overwhelming drug courts and child welfare programs. And conventional urine testing simply can’t provide the monitoring necessary to ensure sobriety. Courts need a better solution that doesn’t demand more staffing.

Reliable Results

Adulteration and incomplete results both create doubt and hinder progress towards recovery. Without a complete understanding of an individual’s use patterns, case managers and courts won’t be able to provide adequate plans for rehabilitation.

Testing should provide an accurate, reliable view into use patterns rather than more doubts. That means reducing the opportunity for tampering with samples and using industry-standard confirmation testing to provide a complete picture with every test result.

Incentivizing Success

Punitive systems won’t prevent overdose deaths. The solution for drug testing in treatment programs needs to provide opportunities for both sanctions and rewards.

And that is only possible when testing can provide a full picture of use rather than just a snapshot. When participants have a tool that helps prove their commitment to sobriety, everyone involved in the recovery process wins.

A New Standard for Drug Use Detection in Treatment Courts

Changing the paradigm for testing changes how testing impacts the effects of fentanyl and stimulants within treatment courts. And PharmChek® does just this.

24-Hour Sample Collection

Once the PharmChek® Sweat Patch goes on, donors know they are accountable for their choices. The patch collects samples that provide a complete view of any drug use ranging from one day prior to application until the patch is removed, up to 10 days later. No other drug testing system provides the same level of accountability.

Tamper-Evident and Environmentally Sealed Design

While urine tests suffer potential adulteration, dilution, and detection issues, the PharmChek® Sweat Patch is designed to expose any attempts to damage or alter the collection patch to influence results. Courts can be confident that PharmChek®’s confirmatory tests are completely accurate every time.

Proof of Sobriety

Case managers want to provide tools that help form new habits rather than just disguising old ones. PharmChek®’s continuous collection offers an ever-present reminder of the importance of remaining clean. And because of its proven and court-supported results, case managers can reward donors when their tests come back negative.

There’s no doubt, no confusion, and no concern that participants are moving in the right direction with their recovery when the Sweat Patch is in their toolbox.

Finding a Way Forward in the Fourth Wave

The opioid crisis is not slowing down. But having the right tools can help courts better address the increases in addictions and overdoses confidently. PharmChek® is the tool that treatment courts and case managers need most for accountability during recovery.

While the lethal combination of fentanyl and stimulants continues to change the face of addiction treatment, court officials can turn to the Sweat Patch for the support they need to keep clients sober and safe.