Charting the Stimulant Overdose Crisis & the Influence of Fentanyl

Although final death statistics are currently available from the Centers for Disease Control and Prevention (CDC) only through 2020, provisional data also compiled by the CDC show deaths involving cocaine and psychostimulants (primarily methamphetamine) continued during the pandemic. The rise is particularly notable for deaths involving psychostimulants (meth), which has surpassed deaths involving cocaine. Factors related to the pandemic, such as stress, social isolation, and using these substances alone, likely contributed to the increase in overdose deaths.

Much attention in the US has been focused on the opioid crisis and rising rates of overdose deaths, driven by the influx of synthetic fentanyl.

In recent years, and somewhat overshadowed by the national focus on the opioid crisis, deaths involving stimulants also rose. Between 2013 and 2020, deaths involving cocaine nearly quadrupled (from 4,939 to 19,429) and deaths involving psychostimulants (primarily methamphetamine) more than sextupled (from 3,616 to 23,776). In 2020, stimulants were involved in 40,568 overdose deaths (a single death may involve multiple substances, including not only stimulants but also opioids and other drugs). Cocaine and psychostimulants (meth) are each involved in more deaths than either prescription opioids or heroin.

Very significant portions of stimulant deaths involve an opioid. Over the 2012-2020 period, as the number of stimulant overdose deaths increased almost sixfold from 6,860 to 40,568, the share of these deaths that involved one or more opioids rose from 43% to 68%.

Moreover, the three waves of the opioid crisis are apparent within these stimulant deaths. In 2012, commonly prescribed opioid medications were the opioid type most likely to be involved in overdoses involving psychostimulants (primarily methamphetamine) and cocaine. In the next few years, there is a rising prominence of heroin. By 2020, deaths involving both of those opioid types have been dwarfed by the explosion of synthetic opioids, primarily fentanyl. In 2020, 49% of deaths involving psychostimulants (meth) and 71% of deaths involving cocaine involved a synthetic opioid.

There is growing concern of fentanyl contamination contributing to deaths involving cocaine and psychostimulants (meth). Fentanyl is approximately 50 times 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.

Stimulant deaths have grown rapidly in recent years, reaching 40,568 deaths in 2020. Since 2000, we have seen the proportion of stimulant deaths involving psychostimulants (primarily methamphetamine) grow - in 2000, approximately 14% of all stimulant deaths involved psychostimulants (meth) alone or in combination with cocaine, but by 2020, this figure was over 58%.

Only a small share of stimulant deaths involved both psychostimulants (meth) and cocaine. Across these two decades, the highest share of deaths with both substances occurred in 2020, at over 6%

Over this period, stimulant overdose death rates have increased in all racial and ethnic groups, but some groups have had a disproportionate increase in deaths. The cocaine death rate among Black or African Americans and the psychostimulants (primarily methamphetamine) death rate among American Indians or Alaskans (AI/AN) surpassed other racial groups in recent years.

The disproportionate increase in stimulant deaths for Black and AI/AN may be partly explained by unequal access to treatment and treatment biases. Research from the CDC found that deaths involving psychostimulants (meth) combined with opioids are most common among AI/AN, while deaths involving cocaine and opioids are most common among Black people.

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). Data was ‘Unreliable’ for AI/AN from 2000 to 2003.

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

Ohio has the highest cocaine overdose death rate with 17.8 deaths per 100,000 in 2020. This is an increase from 10.8 deaths per 100,000 in 2019. West Virginia has the highest psychostimulant (meth) death rate with 38.4 deaths per 100,000 in 2020, up from 24.4 in 2019.

There are significant urban-rural differences in drug overdose death rates, including by stimulants. In 2020, the rate of drug overdose deaths involving psychostimulants (primarily methamphetamine) in rural counties (9.3 per 100,000) was 1.3 times the rate in urban counties (7.2). In 2020, the rate of drug overdose deaths involving cocaine in urban counties (6.4) was more than twice the rate in rural counties (3).

Strategies to reduce drug overdose deaths include promoting evidence-based solutions in prevention, harm reduction, treatment and recovery efforts. Additionally, efforts are needed to improve 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, e.g., 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).

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. 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.