Introducing the Fourth Wave of the Drug Epidemic

Introducing the Fourth Wave of the Drug Epidemic 1024 575 Alaina Doklovic

Drug overdoses and poisoning are the third leading cause of pediatric death. In recent years, there has been a dramatic increase in the number of fentanyl-related overdoses, with 15-19 year olds being the most affected.

In the Ohio illicit drug supply, as shared by the Ohio Narcotics Intelligence Center (ONIC), the emerging drugs, known as novel psychoactive substances (NPS) are a combination of opioids plus sedatives, such as xylazine, (Tranq-Dope) or opioids plus benzos (Benzo-Dope). Synthetic benzos are also an emerging issue. In Ohio, these mixtures have been observed in powder, counterfeit pill, and rock-like forms.

Tranq-Dope

Tranq-Dope is a combination between opioids and sedatives. Currently, one of the most common fentanyl adulterants is xylazine. When fentanyl is adulterated, a patient’s clinical treatment may be longer or the patient may not respond to the traditional antidotes for fentanyl, including naloxone. The most common symptom associated with xylazine is sedation, followed by respiratory depression and bradycardia.

“When people are exposed to drugs such as xylazine, sedation is one of the primary symptoms,” says Hannah Hays, MD, chief of Toxicology at Nationwide Children’s Hospital and medical director of the Central Ohio Poison Control Center. “These adulterants last a lot longer than the sedation we see from fentanyl.”

Benzo-Dope

Benzo-Dope is a combination between opioids and benzodiazepines. With new opioids and benzodiazepines emerging in the illicit drug supply, the risk of overdose and negative health outcomes is significantly increasing.

“We are currently in the fourth wave of the drug epidemic”, says Kelsey Schmuhl, PharmD, BCACP, ambulatory pharmacist at Nationwide Children’s and clinical assistant professor at The Ohio State University College of Pharmacy. “This is categorized by polysubstance use and counterfeit tablets. As fentanyl has become more controlled, this has helped pave the way for a new class of opioids: benzimidazole opioids or ‘nitazenes’.”

Nitazenes were first synthesized in the 1950s as a substitute for morphine but were never brought to the market. They finally emerged on the illicit drug market in 2019 and are potentially up to 40x more potent than fentanyl.

For benzodiazepines, a common category of NPS are designer benzodiazepines, specifically bromazolam.

“Structurally, these look like alprazolam, or Xanax. So many people think they are getting alprazolam in a tablet, but they might be contaminated with some designer benzos, such as these benzodiazepines,” says Dr. Schmuhl. “Adolescents may be more attracted to these because they come in tablets, which adolescents are more likely to be experiment with, and because they come in a rainbow of colors.”

Fentanyl, NPS and Testing

Fentanyl adulterants – including xylazine and benzos – are also often not detected on drug screens, which can be problematic even for opioid testing.

“Even the opiate drug screen does not detect fentanyl. You would need a special fentanyl screen that is not even available in many places,” says Dr. Hays. “Additionally, a positive test also does not imply impairment because a drug screen can be positive for two to four days or longer, even when a patient is not currently intoxicated.”

Fentanyl is no longer considered an NPS, but it is still a major problem. It is involved in the majority of opioid-related overdose deaths. According to the Drug Enforcement Administration (DEA) about 7 in 10 counterfeit tablets that have been confiscated contain fentanyl. It is common to find fentanyl mixed with adulterants or contaminants, usually without the knowledge of the person using it.

Help Is Available

If patients, families or health care professionals have questions about medications or drugs, the poison center is available 24 hours a day, seven days a week for free, confidential advice. The poison center can be reached at 1-800-222-1222.

Additionally, the Substance Use Treatment and Recovery Program at Nationwide Children’s Hospital offers assistance for people with substance use ages 12 to 25. This program is located at the Livingston Ambulatory Center and aims to create the best treatment plan for the patient and family and connect them with the best health services.

About the author

Alaina Doklovic is a Marketing Specialist for Research Communications at Nationwide Children’s Hospital. She received her BS in medical anthropology and English from The Ohio State University. Her passions for science and health, combined with her desire to help others, motivated her to pursue a career in which she could actively help improve patient outcomes and scientific research through writing.