However, there’s also bad news in that increasing numbers of illicit users of stimulants like cocaine or methamphetamine are being poisoned by fentanyl-adulterated drugs, particularly in the Western part of the country. For example, a regional analysis of overdose deaths from fentanyl in the United States published in May 2025 revealed in the West, one in two deaths from drugs are currently linked to fentanyl contamination of cocaine or meth, while in the East, one in three fentanyl-related deaths occurred in users of cocaine or methamphetamine.

We have discussed this in detail in my other PT blog posts that the availability of Narcan (naloxone), a drug that reverses overdose, is largely responsible for significantly fewer opioid deaths from opioids. However, more stimulants, particularly cocaine and methamphetamine, are now being used with fentanyl, contaminated with fentanyl. Unfortunately, we don’t have a drug like Narcan to reverse speedballing (ingestion of both a depressant and a stimulant) or cocaine or methamphetamine overdoses.

Latest 2025 Update

The opioid crisis, currently driven by synthetic opioids such as illicitly manufactured fentanyl (IMF), is increasingly complex. Adulteration of IMF with veterinary sedatives, such as xylazine and now medetomidine, is creating zombie addicts and overdose nightmares. This adulteration has become commonplace across the United States, leading to prolonged sedation that cannot be reversed with just naloxone. The dangerous and deadly shift accelerated from plant-based drugs, like heroin and cocaine, to synthetic, chemical-based drugs, like fentanyl and methamphetamine.

Clinicians, harm-reduction experts, and others continue adapting to the drug cartel’s changes in the drug supply, such as testing drug products for the presence of other drugs and using oxygen when treating people with overdoses. In a May 21 JAMA, Dr. Joseph Palamar at NYU identified a new worrisome trend. Adulteration agents now include lidocaine and other local anesthetics, much as they were added to cocaine back in the 1970s. The local anesthetics can complicate overdose management by lowering pulse and blood pressure and causing confusion and life-threatening seizures.

Evolution of Illicit Drugs and Adulteration

Over the past five decades, the adulteration of illicit drugs such as heroin, cocaine, and methamphetamine has evolved, transitioning from inert bulking agents like sugar to potent pharmacologically active substances. This shift has heightened risks associated with drug use, contributing to increased toxicity and overdose fatalities.

When I was working at Yale with Herb Kleber in the 1970s–1980s, adding inert adulterants was the norm for illicit drug producers. During this period, heroin was commonly adulterated with sugars (e.g., lactose, maltose) to increase the weight and volume of the drugs and, thereby, their profits. However, in the late 1970s, our colleague David Smith saw the emergence of “China White” overdoses in Haight Ashbury, a highly lethal and potent synthetic opioid—methylfentanyl mixed with heroin. At Yale, we saw cocaine emergencies and found cocaine was typically cut with local anesthetics like lidocaine and procaine to mimic cocaine’s numbing effect and improve profits, as well as sugars and caffeine to increase bulk. We did not see many methamphetamine cases at all but, when meth was adulterated, it was with caffeine or other stimulants to enhance its effects.

The 1990s marked an era of wholehearted adulteration with pharmacologically active adulterants. For example, heroin included adulterants like quinine and other substances that could either potentiate the stimulant’s effects or mimic heroin’s appearance. The range of adulterants expanded further, to include pharmacologically active substances such as levamisole, a veterinary agent which became widespread in the 2000s. The State Department’s expert, Tom Browne, reported on these trends and warned that levamisole in heroin or cocaine could cause toxic and severe health issues. Methamphetamine adulteration began to include substances like pseudoephedrine and other byproducts from illicit synthesis processes.

The 2010s–2020s were marked by the emergence of highly potent synthetic adulterants. The illicit drug market saw a surge in the use of fentanyl and its analogs as adulterants in heroin, dramatically increasing the risk of fatal overdoses due to fentanyl’s high potency. Fentanyl adulteration and contamination extended to cocaine supplies, leading to unexpected opioid overdoses among stimulant users. Methamphetamine began to be adulterated with potent synthetic substances, including fentanyl, increasing the danger of overdose.

Drug overdose deaths also became the leading cause of injury death in the United States, in 2015, surpassing deaths by motor vehicles and firearms. In 2020, 83,000+ people died from drug-related overdoses, a significant increase from 2019. Illicit fentanyl, an extremely potent drug, was the primary driver of these deaths. Often, users had no idea their opioid was contaminated with fentanyl.

In 2015, the DEA noted that both controlled prescription drugs and heroin abuse were prevalent, with some prescription drug abusers initiating heroin use. By 2020, the situation changed, and illicit fentanyl, primarily produced by Mexican cartels using Chinese precursor chemicals, became the primary threat. DEA laboratories also reported a downward trend in the purity of fentanyl. For example, medetomidine, a powerful veterinary anesthetic, emerged in the fentanyl supply, posing new dangers, and the zombie drug Xylazine remains the top adulterant found in fentanyl powder.

Worldwide, We Are Still Number 1 in Drug Deaths

Provisional data indicate that an estimated 80,391 overdose fatalities occurred in the United States in 2024, a 27 percent decrease from 110,037 deaths in 2023. This represents the largest single-year drop since the Centers for Disease Control and Prevention began tracking overdose deaths 45 years ago. Nearly all states experienced declines, with significant reductions (≥35 percent) in Louisiana, Michigan, New Hampshire, Ohio, Virginia, West Virginia, Wisconsin, and Washington, D.C. While the Centers for Disease Control shows a 27% decline in overdose deaths in 2024. Still, during that 12-month period, Nevada saw a 3.4% increase. Unlike the rest of the nation, in Nevada, methamphetamine is causing more drug-related deaths than fentanyl at this time.

In 2024, the U.S. deaths decreased to the lowest since 2019. However, even with this progress, the United States still maintains the highest overdose death rate worldwide. Despite a significant decline in drug overdose deaths in the United States, we still have the highest overdose death rate in the world, with 324 deaths per million people, significantly surpassing other nations. Scotland was second, with 218 deaths per million people. Canada is ranked third globally in overdose death rates. For opioid overdose deaths, the United States is also number one with 15.4 overdoses per 100,000; Canada has 6.9, and Europe and Russia have fewer than 4 opioid overdoses per 100,000.

Summary

The new DEA national threat findings note that today, one in eight methamphetamine samples contains fentanyl, and one in four cocaine samples contains fentanyl. This adulteration heightens risks for unintentional overdoses among users. Adulteration with multiple, active synthetics is evolving and creating more risks than ever.

Overdose deaths remain the leading cause of death for Americans aged 18–44, and an unacceptable 80,000+ Americans per year die from overdoses. Regional differences are becoming more critical—methamphetamine + fentanyl in the Western United States versus cocaine + fentanyl in the East. Fentanyl is cheap to produce, so today it’s often the first choice of an active adulterant among drug cartels.

Source: https://www.psychologytoday.com/us/blog/addiction-outlook/202505/abuse-drugs-and-trends-were-up-against-in-the-us