Latest Data: Combination Drug Use Increases Overdoses

Synthetic opioids and stimulants have been increasingly involved in overdose deaths since 2015. In 2011, the overdose crisis was primarily driven by prescription opioids. Deaths involving prescription opioids have remained consistent while heroin’s involvement in overdose deaths began declining in 2016.

The source of fentanyl driving the increase in synthetic opioid-involved deaths is more likely to be illicitly manufactured than pharmaceutical. Overdose deaths increased when COVID-19 lockdowns began in March 2020. Factors related to the pandemic, such as stress, social isolation, and using these substances alone, likely contributed to the increase in overdose deaths.

Although final death statistics are currently available from the Centers for Disease Control and Prevention (CDC) only through 2021, provisional data also compiled by the CDC show drug overdose deaths plateauing in 2022.

Because a single death may involve multiple types of drugs, therefore summing across the categories in any year will overstate the total number of deaths in that year.

Xylazine is an animal sedative not approved for human use. It is increasingly being detected in fentanyl. Addiction treatment centers do not have the expertise to treat the severe wounds xylazine causes, limiting treatment options for people who are addicted.

Xylazine has no known antidote, but naloxone should be administered even if it is suspected to be present because xylazine is usually found in synthetic opioids, which do respond to naloxone. There is a new dual drug test strip that can detect fentanyl and xylazine.

• Fentanyl: Fentanyl. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. June 1, 2022
• Xylazine: What You Should Know About Xylazine. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. July 17, 2023.
• Data: Kariisa M, O’Donnell J, Kumar S, Mattson CL, Goldberger BA. Illicitly Manufactured Fentanyl–Involved Overdose Deaths with Detected Xylazine — United States, January 2019–June 2022. MMWR Morb Mortal Wkly Rep 2023;72:721–727.

Very significant portions of stimulant deaths involve an opioid. Over the 2011-2021 period, as the number of cocaine overdose deaths increased more than 5x, the share of these deaths that involved synthetic opioids rose from 4% to 74%. The number of methamphetamine overdose deaths increased more than 14x over the 2011-2021 period, and the share of these deaths that involved synthetic opioids rose from 4% to 58%.

There is growing concern of fentanyl contamination contributing to deaths involving cocaine and methamphetamine. Fentanyl is approximately 50x as potent as heroin and is being mixed with illegal drugs, which increases risk of overdosing. Many people are unaware that their drugs are laced with fentanyl. It is often added to drugs because it is extremely potent, which makes drugs cheaper and more addictive.

As the number of opioid and stimulant overdose deaths grew between 2000 and 2021, the minutes between deaths fell correspondingly. By 2021, one person was dying of an opioid-related overdose every 6.61 minutes, and one person was dying of a stimulant-related overdose every 9.84 minutes.

Over this period, overdose death rates have increased in all racial and ethnic groups, but disparities exist between some groups. The opioid and methamphetamine death rate among American Indians or Alaskans are higher than other racial groups. The cocaine death rate among Black or African Americans is higher than other racial groups.

Race and ethnicity were used as defined in the WONDER and NCHS databases. Racial and ethnic groups were defined first by ethnicity (Hispanic or Latino) and subsequently by race (non-Hispanic American Indian or Alaska Native, non-Hispanic Black or African American, non-Hispanic White, and non-Hispanic Asian or Pacific Islander). The data was collected using WONDER Multiple Cause of Death, 2018-2021, Single Race Categories, which are not available prior to 2018.

Overdose death rates varied by age across opioid and stimulant-related deaths. Individuals ages 35-44 years old had the highest rate for opioid-related overdose deaths, followed by those 25-34 years old. Methamphetamine-related death rates were highest among individuals ages 35-44 years old, followed by individuals ages 45-54 years old. Cocaine-related deaths were highest for individuals ages 45-54 years old, followed by 35-44 years old.

While stimulant overdose deaths are affecting the entire US, there are some clear geographic variations in the impact of cocaine and methamphetamine.

The District of Columbia had the highest cocaine-related overdose death rate with 32.1 deaths per 100,000 in 2021 and West Virginia had the highest methamphetamine-related death rate with 49.8 deaths per 100,000 in 2021.

The burden of opioid-related deaths is also spread unevenly across the U.S., with concentrations in the midwest and Appalachian region. In 2021, West Virginia had the highest death rate with 76.5 deaths per 100,000 individuals.

Strategies to reduce opioid, stimulant and xylazine-related overdose deaths include promoting evidence-based solutions in prevention, harm reduction, treatment and recovery efforts. Additionally, efforts are needed to improve research and data collection. This includes the collection of timely and local data, making real-time data available for analysis, and using gathered information to inform community-tailored interventions.

Data on drug overdose deaths were derived from the multiple cause of death files of the Wide-ranging Online Data for Epidemiologic Research (WONDER) data system maintained by the Centers for Disease Control and Prevention (CDC).

Deaths were identified as due to an opioid overdose if the ICD-10 code for the underlying cause of death was X40-X44 (accidental poisoning), X60-X64 (intentional self-poisoning) or Y10-14 (poisoning of undetermined intent). A small number of overdose deaths that were the result of homicide (underlying cause of death X85) were excluded from the analyses.

Within this group of overdose deaths, the substances involved in the overdose were identified using the multiple cause of death codes: T40.1 (heroin), T40.2 (natural and semi-synthetic opioids), T40.3 (methadone) or T40.4 (synthetic opioids other than methadone), T40.5 (cocaine) and T43.6 (psychostimulants with abuse potential, primarily methamphetamine). Because a single death may involve multiple substances, summing across the number of deaths involving each substance will overestimate the number of drug overdoses. Following the classification scheme adopted by the CDC, methadone and natural and semi-synthetic opioids (e.g., oxycodone and hydrocodone) were grouped into a single category encompassing commonly prescribed opioids. Synthetic opioids other than methadone include substances such as tramadol and fentanyl (both pharmaceutically manufactured and illicitly manufactured). For the purpose of this infographic we refer to drugs under the code T43.6 as methamphetamine.

Provisional death data come from the CDC’s National Center for Health Statistics Provisional Drug Overdose Death Counts. Provisional death data are based on death records submitted by state vital registration offices and vary in their timeliness for both reporting and validation. The counts given for a specific month capture all death reports for the prior twelve-month period ending in that month, making the counts insensitive to variation in reporting across seasons. In addition to the raw provisional counts, the CDC also provides predicted provisional counts that have been adjusted to account for reporting and validation delays. The graphic we show is based on these predicted provisional counts. Provisional data are subject to change and are not strictly comparable with final annual death counts reported elsewhere.

The xylazine data was sourced from a CDC Morbidity and Mortality Weekly Report (MMWR) published June 30, 2023.