Drug overdose deaths involving cocaine and psychostimulants such as methamphetamine have been rising quickly in the United States in recent years, and a new report from the US Centers for Disease Control and Prevention shows that opioids are also involved in most of those deaths.
In 2021, opioids were present in about 79% of overdose deaths involving cocaine and about 66% of those involving psychostimulants, according to CDC data. And these multi-drug combinations have become increasingly common.
Overdose deaths involving both cocaine and opioids have become more than seven times more frequent over the past decade, growing from less than 1 death for every 100,000 people in 2011 to nearly 6 in 2021. And those involving both psychostimulants and opioids became 22 times more common, jumping from 0.3 deaths for every 100,000 people in 2011 to nearly 7 in 2021.
Deaths from cocaine or psychostimulants that did not also involve opioids also increased, but they grew at significantly slower rates.
“The epidemic is showing us that it is quite dynamic and it can change quite rapidly,” said Katherine Keyes, an associate professor at the Columbia University Mailman School of Public Health, who was not involved in the new report but whose research focuses on psychiatric and substance use epidemiology. “This data is a stark reminder of how much more we need to be doing to combat these very preventable deaths.”
Although the new CDC report does not specify the type of opioids involved, experts say that these trends highlight the dangers of illicit fentanyl, a powerful synthetic opioid.
“Cocaine combined with fentanyl is much more toxic and lethal. Methamphetamine can kill more than cocaine by itself, but having said that, it’s much more dangerous when you combine it with fentanyl,” said Dr. Nora Volkow, director of the National Institute on Drug Abuse, who also was not involved in the new research. “This accounts for why we’re seeing firsthand a high rise in mortality from these two drugs.”
But fentanyl isn’t the only factor, and addressing the deadly overdose epidemic in the US will require multiple strategic approaches, experts say.
“The dramatic rise in cocaine- and methamphetamine-involved deaths over the past decade emphasizes that this is a polysubstance overdose crisis, not an opioid crisis, and that we need a range of proven interventions to save lives,” said Dr. Sarah Wakeman, an addiction medicine physician at Mass General Brigham, who was not involved in the new report.
Both intentional and unintentional combinations of these drugs are probably contributing to rising overdose death rates, she and others say.
The use of opioids along with stimulants has long been common among drug users: for decades with cocaine and more recently with psychostimulants such as methamphetamine.
“Research has shown that people who are using both stimulants and opioids are at even higher risk of health-related complications, and treatment models addressing both are more limited,” Wakeman said.
But fentanyl has also contaminated the illicit drug market, raising the risk of unintentional exposure.
Dealers “are diluting that drugs that are more expensive to manufacture and adding fentanyl,” Volkow said. “They put a tiny little bit of fentanyl, which is less expensive but so potent that it will generate a powerful substance.”
This is particularly true for cocaine, which is more expensive to manufacture and transport, helping explain why the new CDC report found the combination of cocaine and opioids to be so common, she said. And the amount of cocaine coming into the US has increased significantly.
“The more drugs that get into the country, the greater the number of people that are going to be exposed to the practice of mixing these drugs with fentanyl in the illicit market,” Volkow said.
About 110,000 people in the US died from a drug overdose in the past year, according to another data set from the CDC that tracks overdose deaths through February. About a quarter of those deaths involved cocaine, and a third involved psychostimulants such as methamphetamine. More than two-thirds involved opioids.