Dr. Todd Korthuis is a professor of medicine and public health affiliated with the Oregon Health & Science University. His recent paper with the National Rural Opioid Initiative on the relationship between methamphetamine use, opioids, and nonfatal overdoses in rural communities alerts readers to some alarming drug trends. In a study of rural communities across 10 states it finds that “79% of people using drugs reported past-30-day methamphetamine use,” and that non-fatal overdose was most common among substance users who reported use of both methamphetamine and opioids. The project highlights the need for more research on treatment for meth addiction and on the co-use of stimulants and opioids, which may be growing ever more common.

Enjoy our conversation about the “eastward march” of methamphetamine use, the real meaning of the term “stimulant-related overdose,” and the importance of culturally-tailored treatment options, below.

Olivia Weeks, The Daily Yonder: What is the context for this study? How did past research and current illicit drug trends necessitate or inspire this inquiry?

Dr. Todd Korthuis: Most of what we know about the overdose epidemic comes from urban areas. Many rural communities have been overlooked in assessing the impact of opioids and other drugs like methamphetamine, and the potential solutions may look different than in urban areas. The Rural Opioid Initiative sought to fill this information gap to better understand how drug use plays out in rural America and identify ways to reduce overdose in these communities.

DY: The idea of stimulant-related overdose is a tricky one. Can you help me tease out all the different types of overdoses we’re concerned with regarding the co-occurring use of methamphetamine and opioids?

TK: When someone overdoses on methamphetamine alone, they may look “over-amped” with agitation, high blood pressure, and stimulation of the cardiovascular system that can lead to heart attacks and strokes. This probably accounts for a minority of methamphetamine related overdoses. Most methamphetamine-related overdose are due to combination with opioids (now mostly fentanyl), either knowingly or unknowingly. Fentanyl and its synthetic analogues are 50 to 100 times more potent than heroin, and now the leading opioids to which most people are exposed. Methamphetamine and cocaine can be laced with fentanyl so that people don’t realize they’re being exposed to an opioid that can rapidly cause an overdose. Also, fentanyl and its analogues have largely replaced heroin and opioid analgesics in the illicit drug supply. If someone is using a non-prescribed opioid or benzodiazepine, they’re probably being exposed to fentanyl. Also, fentanyl doesn’t show up on an opioid drug screen. Most medical examiners don’t test for fentanyl, so a lot (most?) of overdose deaths attributed to stimulants are likely fentanyl deaths.

DY: The study shows that, “among respondents reporting any methamphetamine or opioid use, the majority used both methamphetamine and opioids.” This might seem counterintuitive to some, as these drugs have seemingly oppositional effects. Why is co-use so common? Has there been a significant increase in this type of drug use over time? If so, what accounts for it?

TK: At least two things are going on: 1) When I started treating patients for substance use disorder about 16 years ago, most people tended to use either methamphetamine or heroin, but rarely both. That has changed over the past 10 years or so. Now most of the patients I see are using both methamphetamine and opioids, even if they prefer one over the other; 2) When fentanyl began to contaminate the methamphetamine drug supply, some people began developing tolerance to opioids, causing them to crave both drugs.

DY: You describe an “eastward march” in methamphetamine use in the past decade. Do policy makers know what to do about that? Are communities that are less experienced with methamphetamine able to provide adequate treatment? For that matter, are communities that are experienced with methamphetamine?

TK: This was a surprise to most of the investigators. We all expected to hear a lot about opioids and see methamphetamine in the West, but respondents reported a lot more methamphetamine use in the Midwest, South, and New England than we had anticipated. All communities struggle with providing treatment for methamphetamine use. We need to better integrate treatments that work for methamphetamine, like contingency management, into rural opioid treatment approaches. This will be challenging and require a lot of support from policymakers and the treatment community.

Dr. Todd Korthuis is a professor of medicine and public health with the Oregon Health & Science University (photo provided).

DY: Your work shows that unhoused and Native American people face even higher risks. What are some strategies that could be used to target help for these populations?

TK: Housing is a challenge everywhere but didn’t used to be as much of a problem in rural communities like the one I grew up in. With the loss of rural jobs and increases in drug use, it’s now much more common. The solution requires a coordinated community response from the health care system, schools, churches, and law enforcement to help people get housing and substance use treatment. The best responses are local and will look different in each community.

Native American communities have long been at increased risk for drug and alcohol problems, having dealt for centuries with social challenges that have only been present in other rural communities for the past few decades. We need more culturally-tailored and community-driven responses in tribal communities. Examples of places that do this really well are the didgwalic wellness center in Washington state and Great Circle Recovery in Oregon. They are able to innovate and tailor treatment in a way that resonates with Native Americans, and can even become a rural treatment resource for non-Native Americans in their surrounding communities. Greater federal support for treatment and prevention services to tribes is also needed.

DY: What do you think the most straightforward conclusions are for the healthcare and treatment industries? Have we learned any lessons from the overdose epidemic that might be applicable to these concerning trends in stimulant use?

TK: Integrating attention to methamphetamine into our treatment and prevention services is an essential step in decreasing overdoses in rural America.

Overdoses seem to continue to rise regardless of the drug of the moment. We need to build community public health capacity and infrastructure that can detect the next big problems as they emerge, and respond nimbly to those challenges with evidence-based prevention and treatment responses.

This interview first appeared in Path Finders, a weekly email newsletter from the Daily Yonder. Each Monday, Path Finders features a Q&A with a rural thinker, creator, or doer. Join the mailing list today, to have these illuminating conversations delivered straight to your inbox.

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