***Article first published by 'Med Page Today' on July 17, 2018***

WASHINGTON -- Fentanyl is increasingly appearing in commonly abused drugs including heroin, cocaine, and marijuana, creating new challenges for physicians, said healthcare officials and emergency room doctors at an event here Tuesday.

While doctors have known for some time that patients frequently overdosed on a combination of opioids and alcohol, or opioids and benzodiazepines, there has been a new trend emerging: "Fentanyl is being used to lace a wide variety of drugs, including marijuana," said Nora Volkow, MD, director of the National Institute on Drug Abuse, speaking at a Politico Pro 2018 Summit panel.

Physicians and policy experts are seeing overdoses due to multiple drugs taken by one person, and in some instances that individual may not even be aware of their own polypharmacy.

Opioids and fentanyl in particular are highly addictive, creating a business opportunity for drug pushers, she suggested.

"Even though you don't know that it's the opioid, you'll crave the drug that you had that sensation with and therefore seek the same dealer," Volkow continued.

As a result, her agency is seeing "a significant increase" in overdoses from cocaine and methamphetamine, "presumably also combined with other drugs."

This creates new challenges for clinicians, she said.

Two weekends ago, Philadelphia emergency physician Jeanmarie Perrone, MD, said her department witnessed "a surge," with six or seven overdoses every night.

"When the patients woke up after they received Narcan, they said that they had only been doing cocaine and that they had no idea that there were opioids in their cocaine," said Perrone, a summit speaker and director of Medical Toxicology for the University of Pennsylvania Perelman School of Medicine.

This is not the same as patients who admit to using multiple drugs, Perrone noted.

"I wonder if this is an even intentional adulteration to expand the population of opioid users ... That panics me even more," she said.

Said Volkow, "We are seeing that even though the mortality rate is very high, it continues to climb, which means more individuals are getting exposed to these drugs."

Seeking Solutions

Even though her emergency room has services to quickly connect those with addiction issues to services -- presumably following an overdose -- Perrone said she is amazed by how often people aren't ready for treatment.

"Despite the fact that we're presenting a solution, they don't see it as a solution," she said, perhaps because it is being offered by physicians.

Recently, Perrone's hospital expanded the care teams to include individuals in recovery. Certified recovery specialists, as they are known, serve as the patients' advocates and are on call 24/7, she said.

In one program in New York, these specialists arrive at the scene of an overdose or treatment center and continue to follow up with patients for 90 days.

Even if patients reject the offer of treatment at first, "when the treatment issue comes up again, they're more ready and they have a person to turn to," Perrone said. "Having an advocate really makes the treatment pathway much better."

In West Virginia, one of the hardest-hit states by the opioid epidemic, the state's public health commissioner has made addiction treatment and overdose prevention a priority.

Rahul Gupta, MD, MPH, MBA, had his staff conduct an in-depth analysis of every one of West Virginia's 887 overdose deaths in 2016.

After scouring public databases, Medicaid roster, medical examiner reports, birth and death records, as well as criminal records, he was able to piece together a portrait of the epidemic's most likely victims. These happened to be men who worked in blue collar jobs, who were between the ages of 35 and 64, and who had less than a high school education.

Through the research, Gupta's staff found that only 71% of people who overdosed had been given naloxone.

So Gupta began requiring all first responders to carry the opioid overdose-reversal drug, as well as having it available in elementary schools and public libraries. He also made naloxone available under a standing order beginning in January.

While overdose deaths in 2017 still grew by about 2% to 909 from 2016, "deaths slowed by about 25% in the second half of the year," the Politico website reported in May.

At the summit, Gupta said he is now focused on predictive modeling.

In a resource-limited environment, it's important to find the people who are highly likely to overdose, so that states like West Virginia can better allocate their resources with the goal of preventing those deaths.

The challenge is getting people connected to treatment, when they are ready for it, Gupta noted.