In an empty stairwell in Pawtucket, R.I., Jackson offered to show a reporter how he tries to reduce his risk of overdosing when he smokes crack cocaine.

(Jackson agreed to speak to The Public’s Radio for this story on the condition that we use only his first name.)

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

Or at least Jackson hoped it was cocaine and not fentanyl, which is linked to nearly 80% of all overdose deaths in Rhode Island in 2022. 

He flicked his lighter to “test” his supply. If it has a “cigar like sweet smell,’’ he said, it means that his cocaine is laced with “fetty” or fentanyl. He put the pipe to his lips and inhaled. “No sweet,” he said, reassured. 

But it was false reassurance. It’s actually impossible to tell for sure if a drug contains fentanyl by the taste or smell. And a mistake can be fatal.

“Somebody can believe that they can smell it [fentanyl] or taste it, or see it…but that’s not a scientific test,’’ said Dr. Josiah “Jody” Rich, an addiction specialist and researcher who teaches at Brown University. “People are gonna die today because they buy some cocaine that they don’t know has fentanyl in it.’’

The combination of cocaine and methamphetamines with fentanyl – a synthetic opioid 50 times more powerful than heroin – is driving what experts call the “fourth wave” of the opioid epidemic. 

Rhode Island had the country’s fourth-highest rate of overdose deaths involving cocaine in 2022, according to the U.S. Centers for Disease Control and Prevention (CDC). 

Racial and ethnic disparities 

As in much of the Northeast, the combination of cocaine and other illicit stimulants with fentanyl is taking an especially steep toll here on Hispanic and Black men. 

“I see the effects that it has on families,’’ said The Rev. Howard M. Jenkins, Jr., who leads a predominantly Black congregation at the Bethel African Methodist Episcopal Church in Providence. “I’ve heard people say, ‘My son just went to bed…And when I walked in there, he was dead.’”

Earlier this year, he said, three people from his church all had friends whose kids overdosed. 

Measured as a portion of the population, overdose deaths among Black Rhode Islanders during the first half of 2023 were higher than any other racial or ethnic group – 55.2 per 100,000, compared with 37.5 for Hispanic residents and 35.6 for White residents, according to state data on preventoverdoseri.org.

Nearly three quarters of the more than 400 fatal overdoses in Rhode Island in 2022 involved two or more substances, according to the most recently available state health data. And as in other Northeast states, that most often meant cocaine and fentanyl.

It’s not clear how much of the latest trend in polydrug use is accidental or intentional. A recent study by Millenium Health said that most people who use fentanyl do so both intentionally and unintentionally. And the high-risk practice of using cocaine or meth with heroin, known as speedballing, has been around for decades. Other reasons include manufacturers adding the cheap synthetic opioid to stretch their supply and dealers mixing up bags. 

But in Rhode Island, researchers said, many people still think they are using unadulterated cocaine — a misconception that can be deadly. 

“Folks who are using stimulants, and not intentionally using opioids, are unprepared to respond to an opioid overdose…because they don’t perceive themselves to be at risk,’’ said Jaclyn White Hughto, a Brown University epidemiologist and a principal investigator in a new, unpublished study called Preventing Overdoses Involving Stimulants (POINTS).

The researchers surveyed more than 260 people in Rhode Island and Massachusetts who use drugs, including some who manufacture and distribute stimulants like 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. 

People who don’t regularly use opioids have lower tolerance, which puts them at higher risk of an overdose. And many of the people interviewed in the study also use drugs alone, so if they overdose they may not be found until it’s too late.

An unknown risk

That’s what happened to Jennifer Dubois’ 19-year-old son, Clifton.

A single mother raising two Black sons, Clifton, her oldest, had been struggling with addiction since he was 14, she said. Clifton also had been diagnosed with ADHD, she said, and mood disorder. In March of 2020, he’d just checked himself into a rehab program, Dubois said, when the state went into lockdown. Clifton called. “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 Clifton showed up at her door. “And I just cried,” she said.

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

Clifton left to stay with family friends in Woonsocket.

In August of 2020, Clifton overdosed. Dubois said that Clifton later confided that he’d been snorting cocaine in a car with a friend.

It took the EMTs two 8-milligram doses of Narcan, an opioid-reversal medication, to resuscitate him. He was rushed to Landmark Medical Center. 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, Clifton was found unresponsive in the bedroom of a family member’s home where he’d been staying. The night before, Clifton 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, like, he was doing better,’’ Dubois said. “I do truly believe Cliff thought he was taking something safe.” 

Unregulated strength

The opioid epidemic’s rising mortality rate among Black and, more recently, Hispanic people in the Northeast, follows a shift in drug use from a market driven by prescription opioids to one dominated by illicit fentanyl, according to a study published in the June 2023 issue of the scientific journal Addiction.  

But the focus on fentanyl as the “killer” misses the point, said Joseph Friedman, an addiction researcher at UCLA and the study’s author. For years, hospitals have safely used medical grade fentanyl for surgical pain because the potency is strictly regulated. “It’s not the strength of fentanyl, that’s risky,’’ he said. “It’s the fact that the potency fluctuates wildly in the illicit market.”

Studies of street drugs, he said, show that in illicit drugs the potency can vary from one percent 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 out to a laboratory. 

Fentanyl test strips offer a low-cost way to prevent overdoses by detecting the presence of fentanyl, regardless of potency, in cocaine and other illicit drugs. The test kits are available for free from harm reduction groups such as Project Weber/Renew.

But the test strips only work if people use them. And not enough people who use stimulants do. 

On the February afternoon when Jackson was preparing to smoke coke, he didn’t wait to find a test kit. 

Jackson, who got hooked on heroin as a teenager in Puerto Rico, quit opioids almost seven years ago, he said, after nearly dying of an overdose. He said that’s when he learned about fentanyl. 

Now, he takes methadone, he said, to treat his addiction to opioids. 

But he still uses cocaine multiple times a day. And when he’s craving his next hit, he tells himself, without a shred of evidence, that what he’s doing is safe.