An old drug re-emerges in Nova Scotia overdose deaths

An illegal drug that's been around for decades has quietly become implicated in a growing number of overdose deaths in Nova Scotia, according to data that suggests the public discussion around drug fatalities needs to broaden beyond the focus on potent opioids.

Overdose deaths in the province linked to cocaine have risen significantly in recent years, mirroring a trend in other jurisdictions, including the United States where they are seeing more deaths involving a mix of opioids and stimulants such as cocaine and methamphetamine. 

"It's very early days in whatever this is, but it's something to watch carefully," Dr. Matthew Bowes, Nova Scotia's chief medical examiner, said of the province's cocaine overdose numbers.

Nearly half of the 79 accidental overdose deaths last year in Nova Scotia involved cocaine, a threefold increase from 10 years ago when it played a much smaller role in drug fatalities. 

The worrying trend comes as the province's health authority said cocaine and the opioid hydromorphone were among the drugs reported to have been used in a "cluster" of suspected overdoses, including a death, on Oct. 15 in Cole Harbour, N.S.

The majority of deaths involving stimulants in Nova Scotia also include an opioid. But what's not clear from the data is if the victims intentionally used both cocaine and opioids, or whether they unknowingly took cocaine tainted by an opioid, something that has been the source of a number of warnings in recent years.

While cases of drugs "laced" with the powerful opioid fentanyl make headlines, UCLA researcher Joseph Friedman, who studies overdose deaths in the United States, said it's more common for people to deliberately take both stimulants and opioids.

The reasons for this are complex, he said, but include fentanyl users turning to cocaine or methamphetamine to "push through" withdrawal from the opioid until they can find the money for their next fix. While opioids lead to drowsiness, stimulants can cause a burst of energy.

Challenges of treating 'polysubstance use'

The rising use of the drugs in combination is important for policymakers and treatment experts to understand, Friedman said. Opioid withdrawal can be treated with medication, but there is nothing similar for stimulants like cocaine and methamphetamine.

"Polysubstance use is really this whole other level of challenge because people are now withdrawing from multiple substances instead of just one thing," he said.

In some areas, such as British Columbia, where more than 10,000 people have died of drug overdoses in the last seven years, officials say fentanyl remains the main lethal driver in what's been called a toxic drug supply.

But that's not the case in some other provinces with lower death rates. This summer, for instance, cocaine was linked to a series of deaths in Newfoundland and Labrador, and medical examiner Nash Denic called the drug the "main killer" in the province.

Newfoundland and Labrador saw 23 overdose deaths between January and September. Of those, 17 were related to cocaine, two involved fentanyl and the remaining four were from a combination of the two drugs.

Tina Olivero, whose 20-year-old son, Ben, died of an overdose in July in St. John's, said his toxicology report revealed he had a half-dozen different drugs in his system. They included both cocaine and a form of fentanyl, but also ecstasy, the ADHD medication ritalin and two types of sedatives.

Olivero said she knew her son, who had an underlying mental illness, had long struggled with a cocaine addiction. She suspects he was unaware he had taken fentanyl, that perhaps his cocaine was contaminated with it, but she knows of other drug users who knowingly take both.

"In Ben's case, he was just following a mind trap," she said. "It was like Groundhog Day, every day waking up having to search for drugs."

Possible 'fourth wave' in overdose crisis

The growing role of stimulants such as cocaine and methamphetamine has been noted in the United States, where the phenomenon has been dubbed the "fourth wave" by some researchers.

The first wave of the opioid crisis began in the late 1990s and involved prescription drugs. Then heroin-related overdose deaths spiked, followed by the third wave involving synthetic opioids such as fentanyl.

Research co-authored by Friedman and published in September indicated evidence of a new wave, and found that a third of overdose deaths in 2021 involved both fentanyl and a stimulant, a 50-fold increase from 2010.

Bowes said that Nova Scotia's data on drug deaths leaves a lot of questions unanswered, and he's in favour of more research into why people might be taking particular drugs in combination.

He's also concerned the focus on opioids overshadows drugs like cocaine. Data released by his office shows that in 40 per cent of deaths linked to stimulants, no opioid was detected.

"It's never good, I think, to focus on one aspect of the problem to the exclusion of the rest of it," he said.