There was perhaps no one subject that drew more debate and scrutiny at the State Capitol this year than how to address fentanyl use in Colorado.
Four legislative committees heard more than 20 hours of public testimony and considered scores of amendments in an effort to curb what one lawmaker called a "tsunami of death." Police and prosecutors from every corner of the state weighed in, as did Gov. Jared Polis and Attorney General Phil Weiser.
Though there's deep disagreement on where that debate should focus, the debate itself made sense: Fentanyl is Colorado's deadliest illicit substance. But far less attention has been paid to the state's second-deadliest drug, one often used together with fentanyl, with a death toll for that's more than tripled in five years: methamphetamine.
In 2021, meth contributed to 734 overdose deaths in Colorado. That's nearly double the number of residents who died by homicide that year, and it's more than 10 times the meth death toll from 2011. More people died from meth overdoses in 2021 than in those tied to heroin, cocaine, prescription pills and alcohol combined.
"People have been overamping and overdosing on meth for years," said Lisa Raville, who runs the Harm Reduction Action Center in Denver, "and we're not talking about it because it’s been overshadowed by heroin, Oxys and fentanyl."
While fentanyl is far more lethal than meth, meth is, in some ways, more complicated. There's no naloxone to reverse a meth overdose. There's no methadone to stop users' cravings. The most effective treatment for meth use is available, by two providers' counts, at just one facility in Denver.
Those complications, coupled with meth's broad availability in the illicit drug market and its profound mental health implications, mean it deserves a similar level of attention as fentanyl, a dozen experts, physicians, law enforcement officials and former users told The Gazette. Why it doesn't, several said, is tied to the lack of treatment options and access for meth use and a stigma that's particularly negative, even relative to other drugs.
The broad societal focus on opioids, while vital to address a deadly disease and change the public's perception of addiction, has in some ways masked what is increasingly a poly-substance crisis, in which meth and fentanyl often intertwine to drive record overdose rates in Colorado and across the country.
Meth "doesn't get a lot of attention because of who it kills: addicts," said Melissa Martin, a former methamphetamine user who's now the director of operations at Tribe Recovery Services.
Meth use isn't new, but isolation and mental health effects brought on by the pandemic have worsened substance use across the board. Drug traffickers, who control both the meth and fentanyl trades, are increasingly mixing the two together, state data and experts indicate, which elevates the overdose risk for a broad swath of users. Treatment access and stigma combine to make it even more difficult for users to escape the grip of methamphetamine, a drug that one physician said is more chemically rewarding than any other substance or activity, from heroin to sex.
"It's more powerful than anyone can imagine unless you’ve been there," said Katie Fiske, a former user who's nearly 10 years clean and is now a certified addiction specialist. "And it’s incredibly powerful. And it’s not because we don’t love our family enough, not because we don’t love our kids enough. We don’t love ourselves enough."
Polluted supply
Back when Fiske first used meth in the early 1990s, it was called crank. The drug was generally made in mom-and-pop-style operations, and it got its name from the motorcycle crankcases it was often transported in.
Fiske was 17, and her cocaine dealer offered her something cheaper and longer lasting. Like many users, Fiske is the daughter of addicts. She endured a childhood of instability and profound trauma, and at its most basic level, meth "makes you feel good, and you forget all your troubles.
"And then before you know it, it's the only thing you can think of," she said from her office in Grand Junction, "and the only thing that matters."
In the nine years and 351 days since Fiske last used, mom-and-pop shops and biker gangs no longer dominate the meth trade. The ingredients once needed to make the drug are now tightly regulated in the United States, and manufacturing has become increasingly consolidated by Mexican drug cartels.
Meth lab busts are down, seizures are up, and the market is flooded with cheap product, said Denver Police Chief Paul Pazen and a spokesman for the Drug Enforcement Administration.
Whether the drug is stronger now is a matter of debate. On its face, meth is less likely to cause overdoses than opioids. As a stimulant, it ramps users up with a surge of euphoria and dopamine. It can cause strokes, overheating and heart attacks. It's toxic to the cardiac and nervous systems, and it carries with it a slew of mental health risks, from anxiety to induced schizophrenia and psychosis. Former users said it took them months of sobriety before their heads began to clear.
But experts said meth alone does not explain why overdoses have surged as much as they have. The primary reason, every person interviewed for this story said, is fentanyl.
Like meth, fentanyl is cheap to make and doesn't require a cultivation process. While fentanyl has fueled a rising tide of overdoses among opioid users, it's also increasingly being mixed into methamphetamine and meth's stimulant cousin, cocaine.
Martin, who handles intakes at Tribe's constellation of recovery homes, said every meth user who arrives seeking treatment also tests positive for fentanyl, often to their surprise and anger.
There are multiple theories as to why fentanyl is being mixed into meth. Don Stader, an addiction medicine physician, said he suspects it's because fentanyl builds a stronger physical dependency and its withdrawals are particularly horrible. While meth has its own withdrawals, any user trying to stop must also now contend with the diarrhea, vomiting, body aches and misery that comes with quitting opioids.
Raville, who through the harm reduction center works to keep drug users alive and safe, said she thinks much of the contamination is likely accidental. Because fentanyl is so potent in small doses, it would be relatively easy for fentanyl and meth to mix when handled by careless traffickers.
Poly-substance use — meaning the use of multiple drugs — can also be intentional on the part of the user. Raville and Pazen, among others, both said that some people, particularly those who are unhoused, will use meth to stay up all night and fentanyl to sleep during the day.
"It's a survival method," Raville said, deployed to avoid theft, arrest, or physical and sexual assault.
Whether the mixture is intentional or not, its effects have been devastating. Of the 734 meth overdoses in 2021, 317 involved fentanyl, more than double the number from 2020, according to state data. Overdoses involving only cocaine have increased only slightly in recent years. But those involving fentanyl have ballooned, from 39 in 2019 to 164 in 2021. That unstable supply — for meth and fentanyl — is why some advocates like Raville have called for legalized, pharmaceutical-grade heroin or meth for users.
Pazen, who had advocated that the legislature make it a felony to possess any amount of fentanyl in any substance, said he wanted laws around meth possession tightened, too, as a way to both lower property crime and address overdose deaths. He said he was told that introducing meth into the conversation would kill the effort to address fentanyl.
"The fact that the meth issue wasn’t addressed at the same time that (fentanyl) was addressed is a clear omission," he said, "that unfortunately we will be paying for with lives lost, with increased crime, with long-term psychosis, and none of those are good for our community."
Stigma and treatment
Fiske called methamphetamine the "ugly stepchild" of the substance use world. Even among drug users, she and others said, meth addicts are particularly stigmatized.
Opioid use can be seen — often correctly — as the result of overprescribing doctors and predatory pharmaceutical companies. During legislative debates, Colorado lawmakers described those who overdosed on fentanyl as victims of the indifference of cartels and their street-level dealers.
To the detriment of users and the resources needed to help them, methamphetamine use does not receive that perspective, Fiske and others said. That compounds the shame that fuels the cycle of substance use.
"Shame will keep you addicted," she said, "and the only way to come out of shame is acceptance."
Meth's status as the "ugly stepchild" is also exacerbated by the difficulty in treating it, experts said. Scott Simpson, psychiatric emergency services medical director at Denver Health, said meth users are "a very challenging patient population to treat."
Users with drug-induced psychosis are often misdiagnosed by providers, given medications they don't need or are turned away from programs elsewhere. Others can be agitated or violent, and pre-existing stigma around meth use further complicates interactions with providers.
Depending on whom you ask, access to substance-use treatment, particularly inpatient treatment, is somewhere between limited and poor in Colorado. But it's even worse for stimulant users, providers said, and they know it.
"It brings tears to my eyes," Fiske said while tearing up. "There are so many lost souls and so many people struggling and fighting to live, and not only physically, but inside. They are fighting to live. Just to live, and I promise you, they’re not living. They’re alive, but they are not living. And they’re fighting for that, and they are hopeless, and they’ve given up, and it's because there’s just not enough help."
"There’s virtually nothing for stimulant users," Raville said. "If someone stands in front of me and says, 'I want to get in to treatment,' and I ask what do you use, and they say meth, I go, 'F---.'"
For opioid users, methadone or buprenorphine can prevent withdrawals and curb cravings. They "level the playing field biochemically," said Jeremy Dubin, the medical director of the Front Range Clinic, and they give users the chance to focus on behavioral and cognitive therapies. When coupled with therapy, those medications are the gold-standard treatment for opioid use.
There are no such medications for meth, complicating its treatment. The most evidence-based treatment for stimulant use, providers said, is called contingency management. Denver Health's contingency-management program lasts 12 weeks, said Wendi Hoag, a therapist at the hospital, and it relies on positive reinforcement. Patients who attend regular therapy sessions can reach into a fish bowl and pull out a card. Some cards had prizes: $10, $25, $50 or $100. Patients with a clean urine test get to pull another card.
"Now, that’s also sometimes difficult to fund because people sometimes get this moral outrage — 'Oh my god, you’re rewarding people with prizes for not doing drugs?'" Stader said. "But that’s the thing that has the most evidence behind keeping people sober off of meth and reducing relapse rates."
But contingency management is minimally available in Colorado. Two providers said only Denver Health offers it in the city. Dubin said the Front Range Clinic was beginning to pilot a similar program. Hoag said she regularly fields emails and calls from providers who want to set up a program, but funding is a challenge. Stader said he knows of doctors who pay for it out of their own pocket.
"You'd have to ask them," Simpson said when asked why more providers don't offer contingency management. "That’s like a theological question. My own soapbox here: They’re difficult diseases to treat. We have big problems with mental health access in Denver and our community. I think a lot of places are just disinterested in treating these patients. I don't know if it's hard, the payment structure is different, if they don't know how. I don't know."
A light
When Fiske was 20, she looked around her living room. Her two sons, both toddlers, were in their rooms. It was dark: The blinds were drawn, and every lightbulb had been plucked from the home's light fixtures and lamps. This was the mid-1990s, before meth pipes were common, and she would smoke out of lightbulbs instead.
She was a few years into her methamphetamine addiction at that point, with two periods of sobriety during her pregnancies. Now, looking around at a room darkened by her substance use, she resolved to get clean. And for a time, she was. Then her new husband was introduced to meth by his coworkers. It would be another 16 years before Fiske quit for good.
There's no stereotypical user, she says: She worked at an urgent care, went to parent-teacher conferences and watched her kids play sports. During those years, she got her children's names tattooed around her left wrist, like a black bracelet. She'd have to look at them every time she pressed a bulb or pipe to her lips.
"Your mind is telling you, 'Don't do this,' while you're watching your body do this," she said. When she used, the emotions and anger and hurt and shame would be shoved into a closet. When she was sober, they washed over her like a river breaking through a dam.
It took nearly 20 years of use, multiple custody battles with the state, countless cycles of shame and a final arrest, but Fiske stopped using in 2012. She will be 10 years sober on June 11, which she proudly says is her new birthday. The tattoo on her wrist, the ink faded and bleeding into itself, is half-covered with a new design: the rabbit from "Alice in Wonderland," "a little psychopath who ran around and never got anything done."
Nearly 30 years since she first used and now an addiction counselor, Fiske has some perspective to share. She wants the same level of funding and attention — for treatment, for stigma, for messaging about who users are — that went to opioids to be applied to meth. She wants education in schools —real education, about what substance is and what it does. She wants resources.
"I think that because there’s limited resources, you go anywhere you can," she said. "Luckily, we happen to be an addiction treatment resource. We get people who come in asking for help, and sadly — yes we can, but it's not a lot.
"But it’s better than nothing."
