Fentanyl, Methamphetamine, and Sedatives: A Hidden COVID Crisis

iceberg above and below the waterline

I live and work in the northeastern U.S., but I keep an eye on news items from around the country, particularly when they’re related to addiction medicine and my role as the chief medical officer for a national treatment provider. While I provide direct care at several of our opioid treatment programs in New Jersey, we have centers across the Midwest, parts of Appalachia, and beyond, including in California.

That’s why I pay attention.

And that’s why a press release I read last year caught my eye — even though it was about events thousands of miles away, all the way over on the other coast.

Late last summer, the California Division of the Drug Enforcement Agency (DEA) issued a stern warning about a dangerous development in Southern California. In the San Diego area, they reported a dramatic increase in overdose deaths connected to the synthetic opioid, fentanyl.

Law enforcement and public health officials backed up the warning by publishing these statistics:

· In the year 2019, there were 152 fentanyl-related overdose deaths in San Diego County — about three (3) fentanyl-related overdose deaths per week.

· In the first six months of 2020, there were 203 fentanyl-related overdose deaths in San Diego County — about eight (8) fentanyl-related overdose deaths per week — which would mean a projected increase of 167% percent in fentanyl-related overdose deaths for the year 2020.

Then, early this year, another press release got my attention.

This one hit closer to home.

The New York Division of the DEA released a warning about an alarming influx of fentanyl and methamphetamine in the New York Area. Their primary areas of concern — aside from their role in enforcing drug laws and combatting drug trafficking in the U.S. — were the deadly nature of both drugs.

The statistics NY area law enforcement officials released show an emerging pattern we all need to know about.

In the fiscal year 2020, DEA and/or police seized:

· 214% more methamphetamine than in 2019

· 59% more fentanyl than in 2019.

Around the same time, New York public health official published a report that showed:

· 440 overdose deaths for the first quarter (Jan-Mar) of 2020

· 80% of those overdose deaths were opioid-related

· 60% of those overdose deaths — opioid or otherwise — involved the presence of fentanyl

These numbers represent increases over 2019, and the 440 deaths reported in the first quarter of 2020 were the highest recorded for any quarter on record: not good news.

Why Addiction Treatment Professionals are Alarmed

These reports — the one from California and the one from New York — are of particular concern in light of our current circumstances:

1. The ongoing opioid epidemic, made worse by the increased presence of illicit fentanyl in the U.S.

2. The denouement of the coronavirus pandemic, which evidence shows has had an adverse impact on social and emotional health, which, in turn, increased risk of alcohol and substance use escalating to alcohol and substance use disorder (AUD/SUD).

3. The practice of cutting a wide variety of illicit prescription drugs — including opioids like Oxycontin, sedatives like Xanax, and stimulants like methamphetamine — with small doses of fentanyl.

Over the past several months, my colleagues and I have seen an increase in fatal and near-fatal overdose encounters involving both illicit prescription drugs and street drugs. Many of these overdoses involve combining drugs like illicit sedatives and opioids with alcohol, while others involve cocaine, heroin, or methamphetamine mixed with fentanyl.

We’re not the only ones who are alarmed. Nor are we the only ones who see a heightened overdose crisis obscured by the coronavirus pandemic. In the DEA press release mentioned above, Special Agent Ray Donovan stated:

“Last month, the CDC Health Alert Network issued an advisory warning that drug overdose deaths significantly increased across the United States, especially deaths involving psychostimulants (methamphetamine) and synthetic opioids (fentanyl). There were an estimated 81,000 drug overdose deaths in the United States from May 2019 to May 2020, justifying a need to alert New Yorkers that drug overdose deaths lurk behind the public health crisis caused by COVID-19.”

When health officials issue warnings, we pay attention. When the DEA gets involved, we get nervous. When health officials and DEA agents from opposite sides of the country issue near-identical alerts and issue warnings within six months of one another, we get more than nervous. To be honest, we feel a sense of impending doom.


It’s the confluence of everything — but right now, it’s the fact that a mix of fentanyl, the pandemic, and the opioid crisis is the very definition of the phrase deadly combination. I want to be clear: this is not a disaster waiting to happen. This is a happening today. The reason we’re not hearing much about it is because issues related to the pandemic — i.e. the vaccine rollout — and issues related to social justice — i.e. the Derek Chauvin verdict, among others things — dominate our headlines.

And although this sounds like a scare tactic straight from the 1950s, doctors and addiction professionals like me around the country are scared because just one dose of illicit fentanyl is enough to kill an otherwise healthy, non-drug using, non-heavy drinking adult.

What Exactly is Fentanyl?

Fentanyl is a synthetic opioid that’s similar to morphine and heroin but 50 to 100 times more potent. It was created as a potent analgesic for patients with severe post-operative discomfort or patients with chronic pain who develop a tolerance to standard opioid medication. However, over the past decade, illicit drug traffickers began producing fentanyl in illegal labs and selling it in various forms, from powder to counterfeit pills that look almost identical to their prescription analogs.

Public health and law enforcement officials report that in addition to using illegally produced fentanyl to mimic common prescription opioids such as Oxycontin, Norco, and Percocet, drug dealers also use illegal fentanyl to “cut” several types of illegal and prescription drugs. I mention this above, but for those who may not be familiar with the term “cut” or “cutting,” in this context it means increasing the apparent volume or amount of a substance by mixing it with another, less expensive substance (fentanyl) in order to maximize profits and reduce cost.

Drugs that may contain illicit fentanyl include:

· Cocaine

· Heroin

· Illicit prescription opioids (i.e. Oxycontin)

· Methamphetamine

· Illicit prescription sedatives (i.e. Xanax)


All these drugs carry risk of addiction or overdose on their own. With the addition of fentanyl, the risk of overdose increases. Medical professionals and law enforcement officials from both coasts recognize the danger. In California, Dr. Glenn Wagner, San Diego County Medical Examiner wrote:

“Today almost all of the fentanyl deaths that we see result from people that have taken counterfeit pills sold illegally as oxycodone or alprazolam (but containing fentanyl instead of the other drugs). These pills are deadly and even just part of one pill kills.”

And in New York, Special Agent Donovan adds:

“We have seen fentanyl mixed with heroin, cocaine, methamphetamine and even marijuana; and it is estimated that 60%+ of all drug overdose deaths in New York City involve fentanyl. Like methamphetamine, fentanyl is produced in ‘Super Labs’ by Mexican trafficking organizations, packaged, and pushed through the border for distribution across the nation.”

The absence of dosage control when fentanyl is mixed with either an illicit prescription drug or an illicit street drug makes the current situation very dangerous for anyone who uses illicit drugs. This includes a group of people that are at particular risk right now: young adults living at home because of economic factors related to the pandemic.

Drug and Alcohol Use Among Young Adults

During the coronavirus pandemic, many people sought to mitigate the stress — and associated mental health challenges — by combining alcohol and drugs for temporary relief. This includes young adults who now live at home under much different circumstances than they expected at this time last year. Some are students who, in the absence of the pandemic, would be away at college. Others are recent college graduates who finished school in the spring and found themselves entering the workforce during a historic economic downturn. Still others are job-seeking high school graduates entering an economy with record unemployment numbers.

And still others are working-class people in their twenties who have returned home and, for various reasons, face economic or personal hardship and attempt to ease the related stress with alcohol and drugs.

Most of these young adults do not want to live at home. They prefer to be in school, have a job, and live independently — yet circumstances mean that for millions of young adults across the country, that’s just not possible.

The latest data from the National Institutes of Health (NIH) Monitoring the Future Survey (2019 MTF) show that young adults 18–24 years old engage in alcohol and drug use at levels that make the recent warnings from the DEA and public health officials ominous:

Drug and Alcohol Use: Young Adults Age 18–24

· Over 30% said they had at least five or more drinks on one occasion in the past 2 weeks

· 63% said they’d used illicit drugs at least once

o 31.2% said they’d used a drug other than marijuana at least once

· 44.3% said they’d used an illicit drug in the past year

o 17.6% said they’d used an illicit drug other than marijuana in the past year

· 29.4% said they’d used an illicit drug in the past month

o 7.6% said they’d used an illicit drug other than marijuana in the past year

When we look at the first bullet point about alcohol use, then read the subsequent data about illicit drug use, then combine these facts with the DEA press reports — from California and from New York — on the presence of fentanyl in several types of legal and illegal drugs, and finally integrate that knowledge with the increase in overdose fatalities and the calls we’ve received about near-overdose experiences among young adults living at home under the stress of the pandemic, we know we have a problem.

A serious problem.

Fentanyl Overdose: What to Look For

The problem is that right now, in California, New York, and everywhere in between, conditions are conducive to accidental overdose for young adults.

This problem is not exclusive to hard-partiers, extreme drinkers, frequent drug users, or people who regularly combine alcohol with recreational drugs.


Because one dose of fentanyl can kill. And the chances of death increase when that dose is combined with alcohol. It’s not a stretch to imagine an otherwise healthy twentysomething who drinks moderately might have a beer and take a pill offered by an acquaintance. Both people may think the pill is a low-dose Xanax, when in fact it could contain a lethal dose of fentanyl.

You can extend that scenario to the other drugs we mention, including marijuana, cocaine, and methamphetamine.

Yes, people who use drugs regularly are at increased risk, but because of the confluence of circumstances we describe — the pandemic, the job market, the presence of illicit fentanyl, and the stats on alcohol and drug use among young adults — so are young adults who would typically be at far lower risk of overdose.

That’s why everyone needs to know the following signs of fentanyl overdose:

· Loss of consciousness

· Unresponsive to external stimuli

· Bluish lips and/or fingertips

· Cold, clammy, pale skin

· Abnormally loud snoring or gurgling/choking sounds

· Slow or erratic breathing

· No breathing

· Irregular or slow heartbeat

· Limp limbs

· Vomiting

If a friend or loved one displays any of the signs, call 911 immediately. Click here to read an emergency overdose response pdf. Here are the steps:

1. Call 911

2. Administer Naloxone, if available

3. Try to keep them awake and breathing

4. To prevent choking, lay the person on their side

5. Stay with the person until medical help arrives

After an overdose or suspected overdose, there’s another thing you can do: seek professional support for a potential alcohol, substance, or mental health disorder.

Final Thoughts: Please Keep an Eye on Your Friends and Family

I tend to end my articles on a positive note, because I’m an optimist. In fact, the last article I published on Medium was called “The Light at the End of the Tunnel.” I discussed the fact that if we can marshal our resources to end the opioid epidemic in the same way we marshalled our resources to face the coronavirus pandemic, we can get the opioid crisis under control.

However, today, I want to end on a serious note. I want you all to watch out for your friends and family members — especially the young adults. They may put on a brave face, but in reality, they’re at risk of developing mental health or drug problems that are directly related to the economic stress and hardship created by the pandemic.

This wave of fentanyl hitting our streets makes any foray into recreational drug use a potentially deadly mistake: according to the DEA, some dealers are even mixing fentanyl with marijuana. That’s why I want you to reach out to your friends, family, and loved ones to check in and let them know you’re there for them — and if you think they’re in trouble, please help them in any way you can.



Christopher Johnston, MD, ABPM-ADM

Christopher Johnston, MD, ABPM-ADM, is the Chief Medical Officer for Pinnacle Treatment Centers and has practiced addiction medicine for the past 15 years