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Stimulant Deaths on the Rise, Compounded by Rise in Synthetic Opioids

Published on: May 13, 2021.

63% of all stimulant deaths

in 2019 also involved an opioid

This interactive graphic series allows users to explore data trends related to the rapid rise in overdose deaths involving stimulants. Stimulants are drugs that speed up the body’s systems. This category of drugs comprises prescription amphetamines (including methamphetamine) used to treat ADHD, narcolepsy and obesity as well as illicitly-manufactured cocaine and methamphetamine. Prescription amphetamines come in pill form intended for slow release, but may be abused by crushing the pills into a powder that can be injected or inhaled for a very quick effect. Illicit methamphetamine and cocaine can also be in a powder form or in crystal form that can be smoked (i.e., crystal meth and crack cocaine).

Tolerance to stimulants develops quickly, causing abusers to need increasingly large doses over short periods of time to maintain the euphoria. The drugs are highly addictive and, among other damaging effects, can cause psychoses and behavioral/mood disorders and a range of serious cardiovascular effects, including elevated body temperature, convulsions, multiple organ failure, sudden cardiac arrest, stroke, and death. Long-term methamphetamine use may also cause severe dental problems and anorexia.

In recent years, much attention in the U.S. has been focused on the opioid crisis, which associated with 49,047 overdose deaths in 2019. Initially a crisis of abuse of prescription pain medications (wave 1) and then heroin use (wave 2), the ready availability of potent synthetic opioids such as fentanyl ushered in a new era of rapidly increasing opioid overdose deaths (wave 3) beginning around 2013. Between 2013 and 2019, deaths involving synthetic opioids increased almost twelve-fold, from 3,102 deaths to 36,303.

At the same time, somewhat overshadowed by the national focus on the opioid crisis, deaths involving stimulants were also on the rise. Between 2013 and 2019, deaths involving cocaine more than tripled (from 4,939 to 15,863) and deaths involving methamphetamine more than quadrupled (from 3,616 to 16,127). In 2019, stimulants were involved in 30,173 overdose deaths (a single death may involve multiple substances, including not only these stimulants but also opioids or other drugs).

Importantly, cocaine and methamphetamine are each now involved in more deaths than either prescription opioids or heroin, both of which have been on the decline in recent years.

Provisional data from the CDC provide an early, but still incomplete, peek at how the drug overdose picture evolved in 2020, particularly as the COVID-19 pandemic took hold. In contrast to a marked uptick observed for deaths involving opioids as the lockdowns began in March 2020, it appears that stimulant overdose deaths continued to increase at approximately the same pace as in the pre-pandemic period. In fact, growth in the number of cocaine-involved deaths actually slowed several months after the lockdowns began.

Stimulant deaths grew very rapidly from 2014 onward, reaching 30,173 deaths in 2019, and methamphetamine was involved in a rising and substantial portion of these deaths. In 2000, approximately 14 percent of all stimulant deaths involved methamphetamine (alone or in combination with cocaine), but by 2019, this figure was over 53 percent.

Only a small share of stimulant deaths involved both methamphetamine and cocaine. Across these two decades, the highest share of deaths with both substances occurred in 2019, at just over 6 percent.

Although stimulant deaths tend to involve only one type of stimulant (cocaine or methamphetamine), very significant portions of those deaths also involve an opioid. Over the 2009-2019 period, as the number of stimulant overdose deaths increased more than fivefold from 5,808 to 30,173, the share of these deaths that involved one or more opioids rose from 40 percent to 63 percent.

Moreover, the three waves of the opioid crisis can be clearly seen within these stimulant deaths. In 2009, commonly prescribed opioid medications were the opioid type most likely to be involved in stimulant overdoses, being present in 26 percent of stimulant deaths. Five years later, the rising prominence of heroin can be detected, with this substance eclipsing prescription opioids as the type of opioid most often involved in stimulant deaths. By 2019, the importance of both of those opioid types has been dwarfed by the explosion of synthetic opioids. Forty-eight percent of all stimulant overdose deaths in 2019 also involved a synthetic opioid.

The rising stimulant death rates and the growing involvement of synthetic opioids is leading to speculation that fentanyl is increasingly being mixed into cocaine and methamphetamine. This may happen accidentally when dealers handle both fentanyl and stimulants, or it may be intentional as a way to stretch the supply of the stimulants. Additionally, some users may intentionally alternate between opioids (which are depressants) and stimulants in an attempt to balance out the highs and lows of these different substances.

Stimulant overdose deaths are affecting different parts of the U.S. differently. In 2019, age-adjusted death rates involving cocaine were higher in Florida, all along the Atlantic coast into New England and westward into the East North Central census division. Florida is a well-known portal for cocaine coming into the U.S. from the Caribbean and South America, and the East coast is a well-travelled trafficking corridor.

In contrast, methamphetamine death rates are higher in the Western U.S., corresponding to the supplies coming from Mexico, and spreading into the center of the country.

In the very early 2000s, stimulant overdose deaths were most heavily concentrated among people between the ages of 35 and 44. Over the next 10 years, people in the 45-to-54-year segments began accounting for the largest share of deaths in any given year, but deaths were less concentrated among any particular age group. As stimulant deaths accelerated after 2014, younger people were increasingly affected and deaths became much more evenly distributed across all ages from 30 to 60 years.

Data and Methods
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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 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), T40.4 (synthetic opioids other than methadone), T40.5 (cocaine) and T43.6 (psychostimulants with abuse potential, e.g., methamphetamine). Following the classification scheme adopted by the CDC, natural and semi-synthetic opioids (e.g., oxycodone and hydrocodone) and methadone 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).

Because a single death may involve multiple substances, it is not possible to sum across the number of deaths involving specific substances to derive the total number of overdose deaths.

Provisional death data come from the CDC’s National Center for Health Statistics Provisional Drug Overdose Death Counts and show stimulant deaths involving cocaine (T40.5) and psychostimulants with abuse potential (T43.6). 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. Graph 2 reflects these predicted provisional counts. Provisional data are subject to change and are not strictly comparable with final annual death counts reported elsewhere.

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