It had been several hours since his last hit, and the chatty, middle-aged man’s hands moved quickly. In one hand, he held a glass pipe. In the other, a lentil-size crumb of cocaine.

Or at least J.R. hoped it was cocaine, pure cocaine — uncontaminated by that was in Rhode Island in 2022. He flicked his lighter to “test” his supply. He believed that if it had a “cigar-like sweet smell,” he said, it would mean that the cocaine was laced with fentanyl. He put the pipe to his lips and took a tentative puff. “No sweet,” he said, reassured.

But this method offers only false and dangerous reassurance. A mistake can be fatal.

It is impossible to tell whether a drug contains fentanyl by the taste or smell. “Somebody can believe that they can smell it or taste it, or see it … but that’s not a scientific test,” said , an addiction specialist and researcher who teaches at Brown University. “People are going to die today because they buy some cocaine that they don’t know has fentanyl in it.”

The first wave of the long-running and devastating opioid epidemic began in the United States with the abuse of prescription painkillers in the early 2000s. The second wave involved an increase in heroin use, starting around 2010. The third wave began when powerful synthetic opioids such as fentanyl started appearing in the supply around 2015. Now experts are observing a fourth phase of the deadly epidemic.

The mix of stimulants such as cocaine and methamphetamines with fentanyl — a synthetic opioid 50 times as powerful as heroin — is driving what experts call the opioid epidemic’s “.” The mixture of stimulants and fentanyl presents powerful challenges to efforts to reduce overdoses because many users of stimulants don’t know they are at risk of ingesting opioids, so they don’t take overdose precautions.

The only way to know whether cocaine or other stimulants contain fentanyl is to use drug-checking tools such as fentanyl test strips — a best practice for what’s known as “,” now embraced by in combating drug overdose deaths. Fentanyl test strips cost as little as $2 for a two-pack online, but many front-line organizations also give them out free.

Nationwide, illicit stimulants mixed with fentanyl were the most common drugs found in fentanyl-related overdoses, according to a in the scientific journal Addiction. The stimulant in the fatal mixture tends to be cocaine in the Northeast, and methamphetamine in the West and much of the Midwest and South.

“The No. 1 thing that people in the U.S. are dying from in terms of drug overdoses is the combination of fentanyl and a stimulant,’’ said , a researcher at UCLA and the study’s lead author. “Black and African Americans are disproportionately affected by this crisis to a large magnitude, especially in the Northeast.”

Friedman was also the lead author of , published in the American Journal of Psychiatry, that shows the fourth wave of the opioid epidemic is driving up the mortality rate among older Black Americans (ages 55-64) and, more recently, Hispanic people. Friedman said part of the reason street fentanyl is so deadly is that there’s no way to tell how potent it is. Hospitals have safely used medical-grade fentanyl for surgical pain because the potency is strictly regulated, but “the potency fluctuates wildly in the illicit market” Friedman said.

Studies of street drugs, he said, show that in illicit drugs the potency can vary from 1% to 70% fentanyl.

“Imagine ordering a mixed drink in a bar and it contains one to 70 shots,” Friedman said, “and the only way you know is to start drinking it. … There would be a huge number of alcohol overdose deaths.”

Drug-checking technology can provide a rough estimate of fentanyl concentration, he said, but to get a precise measure requires sending drugs to a laboratory.

It’s not clear how much of the latest trend in polydrug use — in which users mix substances, such as cocaine and fentanyl, for example — is accidental versus intentional. It can vary for individual users: a recent study from found that most people who use fentanyl do so at times intentionally and other times unintentionally.

People often use stimulants to power through the rapid withdrawal from fentanyl, Friedman said. And the high-risk practice of using cocaine or meth with heroin, ,” has been around for decades. Other factors include manufacturers’ adding the cheap synthetic opioid to a stimulant to stretch their supply, or dealers mixing up bags.

Researchers say many people still think they are using unadulterated cocaine or crack — a misconception that can be deadly. “Folks who are using stimulants, and not intentionally using opioids, are unprepared to respond to an opioid overdose,” said Brown University epidemiologist , “because they don’t perceive themselves to be at risk.” Hughto is a principal investigator in a new, called “Preventing Overdoses Involving Stimulants.”

Hughto and the team surveyed more than 260 people in Rhode Island and Massachusetts who use drugs, including some who manufacture and distribute stimulants such as cocaine. More than 60% of the people they interviewed in Rhode Island had bought or used stimulants that they later found out had fentanyl in them. And many of the people interviewed in the study also use drugs alone. That means that if they do overdose, they may not be found until it’s too late.

In 2022, Rhode Island had the of overdose deaths involving cocaine in 2022, after Washington, D.C., Delaware, and Vermont, according to the Centers for Disease Control and Prevention.

The fourth wave is also hitting stimulant users who choose pills over what they perceive as more dangerous drugs such as cocaine in an effort to avoid fentanyl. That’s what happened to Jennifer Dubois’ son Cliffton.

Dubois was a single mother raising two Black sons. The older son, Cliffton, had been struggling with addiction since he was 14, she said. Cliffton also had been diagnosed with attention-deficit/hyperactivity disorder and a mood disorder.

In March 2020, Cliffton had checked into a rehab program as the pandemic ramped up, Dubois said. Because of the lockdown at rehab, Cliffton was upset about not being able to visit with his mother. “He said, ‘If I can’t see my mom, I can’t do treatment,’” Dubois recalled. “And I begged him” to stay in treatment.

But soon after, Cliffton left the rehab program. He showed up at her door. “And I just cried,” she said.

Dubois’ younger son was living at home. She didn’t want Cliffton doing drugs around his younger brother. So she gave Cliffton an ultimatum: “If you want to stay home, you have to stay drug-free.”

Cliffton went to stay with family friends, first in Atlanta and later in Woonsocket, an old mill city that has Rhode Island’s of drug overdose deaths.

In August 2020, Cliffton overdosed but was revived. Cliffton later confided that he’d been snorting cocaine in a car with a friend, Dubois said. Hospital records show he tested positive for fentanyl.

“He was really scared,” Dubois said. After the overdose, he tried to “leave the cocaine and the hard drugs alone,” she said. “But he was taking pills.” Eight months later, on April 17, 2021, Cliffton was found unresponsive in the bedroom of a family member’s home.

The night before, Cliffton had bought counterfeit Adderall, according to the police report. What he didn’t know was that the Adderall pill was laced with fentanyl. “He thought by staying away from the street drugs and just taking pills, he was doing better,” Dubois said.

A fentanyl test strip could have saved his life.

This article is from a partnership that includes , , and Ñî¹óåú´«Ã½Ò•îl Health News.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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“I don’t know,” she said, her eyes filling with tears. “To go to a doctor that doesn’t know who you are? That doesn’t know what allergies you have, the medicines that make you feel bad? It’s difficult.”

At 71, Fred has never been vaccinated against covid-19. She no longer gets an annual flu shot. And she hasn’t considered whether to be vaccinated against respiratory syncytial virus, or RSV, even though her age and an asthma condition put her at of severe infection.

“It’s not that I don’t believe in vaccines,” Fred, a Colombian immigrant, said in Spanish at her home last fall. “It’s just that I don’t have faith in doctors.”

The loss of a trusted doctor is never easy, and it’s an experience that is increasingly common.

The stress of the pandemic drove a lot of health care workers to retire or quit. Now, a nationwide shortage of doctors and others who provide primary care is making it hard to find replacements. And as patients are shuffled from one provider to the next, it’s eroding their trust in the health system.

The American Medical Association’s president, , recently called the physician shortage a “public health crisis.”

“It’s an urgent crisis, hitting every corner of this country, urban and rural, with the most direct impact hitting families with high needs and limited means,” Ehrenfeld in October.

In Fred’s home state of Rhode Island, the percentage of people without a regular source of routine health care , though the state’s residents still do Americans.

Hispanic residents and those with less than a high school education are less likely to have a source of routine health care, according to the nonprofit organization .

The community health centers known as , or FQHCs, are the safety net of last resort, serving the uninsured, the underinsured, and other vulnerable people. There are more than 1,400 community health centers nationwide, and about two-thirds of them lost between 5% and a quarter of their workforce during a six-month period in 2022, by the National Association of Community Health Centers.

Another 15% of FQHCs reported losing between a quarter and half of their staff. And it’s not just doctors: The most severe shortage, the survey found, was .

In a domino effect, the shortage of clinicians has placed additional burdens on support staff members such as medical assistants and other unlicensed workers.

Their extra tasks include “sterilizing equipment, keeping more logs, keeping more paperwork, working with larger patient loads,” said , executive vice president of District 1199 NE of the Service Employees International Union, which represents 29,000 health care workers in Connecticut and Rhode Island.

“When you add that work to the same eight hours’ worth of a day’s work you can’t get everything done,” Martin said.

Last October, scores of SEIU members who work at , Rhode Island’s largest FQHC, held an informational picket outside the clinics, demanding improvements in staffing, work schedules, and wages.

The marketing and communications director for PCHC, , declined to comment.

Staff discontent has rippled through community health care centers across the country. In Chicago, workers at three health clinics held a in November, demanding higher pay, better benefits, and a smaller workload.

Then just before Thanksgiving at Unity Health Care, the largest federally qualified health center in Washington, D.C., doctors and other medical providers . They said they were being pressed to prioritize patient volume over quality of care, leading to job burnout and more staff turnover.

The staffing shortages come as community health centers are caring for more patients. The number of people served by the centers between 2015 and 2022 increased by 24% nationally, and by 32.6% in Rhode Island, according to the , or RIHCA.

“As private practices close or get smaller, we are seeing patient demand go up at the health centers,” said , RIHCA’s president and CEO. “Now with the workforce challenges, it’s very difficult to meet that patient demand.”

In Rhode Island, community health centers in 2022 served about 1 in 5 residents, which is more than twice the national average of 1 in 11 people, according to RIHCA.

Job vacancy rates at Rhode Island’s community health centers are 21% for physicians, 18% for physician assistants and nurse practitioners, and 10% for registered nurses, according to six of the state’s that responded to a survey conducted by RIHCA for The Public’s Radio, NPR, and Ñî¹óåú´«Ã½Ò•îl Health News.

Pediatricians are also in short supply. Last year, 15 pediatricians left staff positions at the Rhode Island health centers, and seven of them have yet to be replaced.

that some of the biggest are workload and job demands.

Community health centers tend to attract clinicians who are mission-driven, said , who spent years working in health centers before becoming a senior leader of the nonprofit .

These clinicians often want to give back to the community, she said, and are motivated to practice “a kind of medicine that is maybe less corporate,” and through which they can they develop close relationships with patients and within multigenerational families.

So when workplace pressures make it harder for these clinicians to meet their patients’ needs, they are more likely to burn out, Burdette said.

When a doctor quits or retires, , a pediatrician and an internist, often gets asked to help. The week before Thanksgiving, she was filling in at two urgent care clinics in Providence.

“We’re seeing a lot of people coming in for things that are really primary care issues, not urgent care issues, just because it’s really hard to get appointments,” Martin said.

One patient recently visited urgent care asking for a refill of her asthma medication. “She said, ‘I ran out of my asthma medicine, I can’t get a hold of my PCP for refill, I keep calling, I can’t get through,’” Martin said.

Stories like that worry Christopher Koller, president of the , a nonprofit philanthropy focused on health policy. “When people say, ‘I can’t get an appointment with my doctor,’ that means they don’t have a usual source of care anymore,” Koller said.

Koller showing that having a consistent relationship with a doctor or other primary care clinician is associated with improvements in overall health and fewer emergency room visits.

When that relationship is broken, patients can lose trust in their health care providers.

That’s how it felt to Piedad Fred, the Colombian immigrant who stopped getting vaccinated. Fred used to go to a community health center in Rhode Island, but then accessing care there began to frustrate her.

She described making repeated phone calls for a same-day appointment, only to be told that none were available and that she should try again tomorrow. After one visit, she said, one of her prescriptions never made it to the pharmacy.

And there was another time when she waited 40 minutes in the exam room to consult with a physician assistant — who then said she couldn’t give her a cortisone shot for her knee, as her doctor used to do.

Fred said that she won’t be going back.

So what will she do the next time she gets sick or injured and needs medical care?

“Well, I’ll be going to a hospital,” she said in Spanish.

But experts warn that more people crowding into hospital emergency rooms will only further strain the health system, and the people who work there.

This article is from a partnership that includes , , and Ñî¹óåú´«Ã½Ò•îl Health News.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).