Oxy. Heroin. Fentanyl. Everything.

Jonathan Spear was 15 years old when he took hydrocodone for the first time. Doctors had prescribed the pills for his mother’s cancer. The powerful opioid filled Spear with a sense of contented bliss and eased the pain of watching his mother suffer from the disease that would take her life. Spear, now 29, eventually turned to the streets and experimented with a cocktail of pills that included Valium, Klonopin, and Xanax. “One of my favorite things to do was mix drugs and alcohol together,” he said. “It would be a more intense feeling.”

He didn’t always know what he was taking. Once, his grandmother found him passed out on his bedroom floor, blue in the face and struggling to breathe. He recalled waking up on his bed surrounded by first responders. “The ceiling fan was going and there was this bright light,” Spear said. “That was my first overdose.” It wasn’t his last.

Millions of Americans use multiple drugs simultaneously or within a short time period, what the Centers for Disease Control and Prevention calls polysubstance use. The practice is growing in popularity and is complicating treatment efforts, leading some experts and treatment providers to refer to the phenomenon as the “fourth wave” of the addiction epidemic.

The first wave of the opioid epidemic began in the late 1990s as pharmaceutical companies aggressively marketed opioids like OxyContin. Heroin overdoses characterized the second phase starting around 2010. The synthetic opioid fentanyl overran the illicit drug world in the mid-2010s, causing overdose deaths to skyrocket during what has become known as the third wave of the addiction epidemic. The number of people who died from a drug overdose was six times higher in 2021 than 1999, and synthetic opioids accounted for about two-thirds of the nearly 110,000 people who fatally overdosed in 2022.

“We’re seeing a co-occurrence of use with amphetamine stimulants with things like opioids. And that’s leading to just the worst possible situation when it comes to public health and increases in overdoses,” said Jordan Davidson, who manages government affairs for the Foundation for Drug Policy Solutions, a group that opposes drug legalization.

Studies show that 70 to 80 percent of people struggling with substance abuse use more than one substance. According to the CDC, polysubstance overdose deaths are increasing. Users are mixing opioids with non-opioid drugs such as anti-anxiety medications like Valium and Klonopin or stimulants like cocaine and methamphetamine. Dealers often lace illicit prescription pills such as Xanax and Percocet with fentanyl or xylazine, a flesh-eating animal tranquilizer that is taking the illicit drug supply by storm.

Davidson said many people aren’t even aware they’re addicted to multiple substances. “You don’t always know what you’re getting,” he said. “Everything’s laced with fentanyl. So if you’re a user of cocaine, and most of the cocaine you’re using is laced with an opioid like fentanyl, maybe you get physically addicted to that, as well.”

Annie Peters is the director of research and education at the National Association of Addiction Treatment Providers. Peters, who is also a clinical psychologist, said it’s increasingly common for people to use drugs that produce opposite effects. Some users want the effect of a stimulant during the day, but prefer a depressant at night. Or they may use one class of substance to ease withdrawal symptoms of the opposite class, she said.

“What we see a lot is that people think they want to get off of one drug, but they don’t see the others as dangerous,” Peters said. “Particularly cannabis, marijuana, even alcohol and nicotine.”

Using multiple substances complicates detox and treatment. “Different drugs are more dangerous to withdraw from,” said Peters. “It’s a complex situation.” The anti-overdose drug naloxone, often sold as an over-the-counter nasal spray called Narcan, can reverse overdoses caused by heroin, fentanyl, or other synthetic opioids. Those drugs also respond to medication-assisted treatments such as buprenorphine and methadone. The Food and Drug Administration has not approved a treatment for methamphetamine or cocaine. Xylazine does not respond to anti-overdose drugs.

Dr. Timothy Allen, an addiction physician outside Milwaukee, Wis., told me that about 80 percent of his patients who abuse illegal substances are using more than one drug. Patients on multiple depressants are more likely to stop breathing during an overdose, he said. But taking cocaine or methamphetamine alongside an opiate is just as dangerous, since stimulants cause the body to use up its oxygen faster. “They stop breathing, and then they actually die faster,” Allen pointed out. “Because the oxygen is depleted more quickly.”

Allen’s first step is to ease his patients through the agonizing withdrawal process with medications. “The medicine gives me a chance to interact with people, and it gives me a chance to keep them alive long enough in order to engage their faith,” he said. Then, he pairs medical treatment with helping his patients change their perspective toward substances.

“That’s going to affect your social life, and then it’s going to affect your spiritual life,” he said. “I tell people, I find that addiction is a highly spiritual condition.” Allen keeps a list of names of patients he’s treated for addiction and prays for them every day.

Spiritual transformation is a central tenet of Adult and Teen Challenge, an organization operating over 200 rehab programs across the United States. Dolly Thomas is a licensed clinical psychologist who oversees training and counseling for Adult and Teen Challenge of Texas. Thomas said their program is seeing an increased number of students struggling with polysubstance use, which often includes a combination of methamphetamines, alcohol, and several other drugs.

Students undergo a medical detox before joining the yearlong residential program. “But even in that first month, we’re dealing with the residual effects,” Thomas said, adding that more students are dealing with psychosis symptoms since crystal meth is a growing number of individuals’ drug of choice in Texas.

The program takes a Biblical counseling approach to rehab, a method that is uncommon among an increasing number of programs using medication-assisted treatment like suboxone. But their end goal isn’t just sobriety. “The opposite of addiction is not just sobriety. It’s community,” Thomas said. “Addiction grows in the soil of isolation.”

Even after another overdose, Jonathan Spear continued to use multiple drugs and drink about a half-gallon of alcohol every two days. His life fell apart when he started working from home. “I’d have a laptop in front of me and a bottle of liquor,” he said. He eventually lost his job and his apartment.

Spear spent a week detoxing in the hospital. Seven months ago, he packed whatever he could fit in a small backpack, and booked himself into the East Texas Men’s Campus of Adult and Teen Challenge in Deport, Texas. After he finishes the program, he plans to complete a five-month internship so he can help guide other students. He credits his success to spiritual transformation and his determination to change.

Spear said the program shows participants the path to lasting change, but the students also have to put in the work. “God is ultimately the one who makes the changes in our lives, and it transforms us,” he said.