We’ve been bringing the 1980s back — including, unfortunately, the cocaine.
While opioid overdose deaths are mercifully on the decline, more Americans are now using and dying from stimulants, particularly cocaine and methamphetamine. A decade ago, in 2016, there were 10,375 deaths from cocaine overdoses; in 2023, there were 29,449. Meth has seen a similar spike in fatalities, from 9,438 deaths in 2017 to 33,283 in 2023. The drug of choice varies depending on where in the US you are: Cocaine is still king in some parts of the Northeast, while methamphetamines are more commonly used elsewhere.
The surge in stimulant use at the same time the opioid overdose crisis has started to ebb is a warning that drug use doesn’t simply end — it evolves. And the image of somebody being solely a heroin user or a cocaine user is outdated: People use multiple drugs, and they choose different ones for different reasons — which can also increase their risk of death. The drugs themselves are now more complex and likely to be synthetic, adding to the risk that you could be taking something without fully understanding what’s in it.
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These shifts present real challenges to the public health system and public health messaging. The United States spent a generation building treatment and recovery programs to address the opioid crisis. The focus was on prescription painkillers, heroin, and later fentanyl; dependence was managed through proven medications like methadone and buprenorphine, and overdoses could be stopped with a spray of naloxone. There was a dedicated effort to get treatment into the hands of primary care doctors, first responders, and ultimately, people in need.
We have none of the same interventions for cocaine or methamphetamine addiction, or for preventing death once an overdose has started.
“There is no medication for cocaine or methamphetamine,” said Keith Humphreys, professor of psychiatry and behavioral sciences at Stanford University. “Everything under the sun has been tested and nothing has worked.”
The behavioral treatments that do exist are still largely reserved for specialty clinics and aren’t available in the primary care offices that are often people’s first stop in the health care system. The signs and symptoms of a stimulant habit or overdose are not the same as they are for opioids, which means people who use these drugs and their loved ones might not be as likely to recognize them.
If we want to prevent the next drug crisis from becoming as devastating as the last, we’ve a lot of work to do on the specifics. But we can — and should — adopt the same principles that have led to our recent successes in bringing down opioid deaths.
“The technical specific treatment intervention might be different,” Dr. Brian Hurley, an addiction physician and immediate past president of American Society of Addiction Medicine, told me. “But the principles of working with the community, helping create connection, giving people access to evidence-based options are the same.”
How drug use in America is changing
The story of America’s relationship with hard drugs goes something like this: Heroin surged in the post-Vietnam era; cocaine and later crack cocaine became a scourge in the ’80s, provoking the harsh and unforgiving response during the Reagan era; and meth appeared on the scene in the ’90s. By the 2000s, powerful prescription painkillers had seeded the next drug crisis, while cocaine and meth use dropped off sharply. Before stimulants made their recent comeback, opioids — first prescription meds, then heroin, and finally powerful synthetic iterations like fentanyl — were the dominant concern for the better part of two decades.
“Many of the doctors who were out providing treatment in the late 2010s and early 2020s, they had only ever dealt with opioids,” said Richard Rawson, a long-time addiction researcher who is affiliated with the University of California Los Angeles and the University of Vermont. “They really had no idea what to do with this thing.”
But dating back to the mid-2010s, experts say, cocaine and meth have seen a resurgence. Meth has also gotten more potent in the past decade, after its production was taken over by drug cartels. One of the most striking trends in recent drug overdose deaths has been the more recent rise in deaths involving both a stimulant and an opioid.
The experts that I spoke to put the simultaneous use of opioids (particularly fentanyl) and stimulants including cocaine and meth into three different buckets:
- Unintentional co-use. Some people think they are buying cocaine, but they are actually getting cocaine laced with fentanyl. (When researchers have sampled drugs that were confiscated off the street, they have found that a small but meaningful amount of cocaine in the US contains one of those powerful synthetic opioids that sent overdose deaths skyrocketing last decade.) And ingesting even a tiny amount of fentanyl can have deadly consequences, especially for people who have no tolerance for it.
- Intentional recreational co-use. Some people take opioids and stimulants at the same time on purpose because that’s the high they are chasing.
- Symptom management. This is the scenario that has shattered existing beliefs about people being a user of one specific type of drugs. Researchers say that people will take both stimulants and opioids intentionally to manage their addictions. For example, they’ll take a little cocaine to avoid nodding off on fentanyl. If they are going through opioid withdrawal, they will take methamphetamine to reduce the pain and convulsions.
Whatever the reason is, taking opioids and stimulants at the same time puts an even greater strain on your health. Your body can oscillate between different extremes — sometimes going from a sedate state with shallow breathing to being overly amped with heart palpitations — in a matter of minutes. Over the longer term, this kind of frequent drug use taxes your heart and can lead to chronic health issues aside from overdose that we should account for when thinking of the toll of the drug crisis.
We need better tools to address cocaine and meth abuse
The public health system is now trying to adapt to the resurgence of stimulants.
Right now, the most proven treatment for stimulant dependency is called contingency management: In essence, it’s a rewards system that offers people an incentive not to use drugs, and it has been effective in randomized trials. Participants will come to a clinic, give a urine sample, and if their urine is drug-free, they receive a gift card. California received approval in 2021 to launch a pilot program that’s treated more than 10,000 people, Rawson said, with folks staying in their treatment longer and testing negative more often than in the behavioral therapy programs of the past.
Funding has been scarce elsewhere, however: Access to contingency management through Medicaid and most private insurance benefits is limited. Some states, like Rhode Island and Vermont have tapped into their opioid lawsuit settlement money to set up their own programs. But more fundamentally, the concept has drawn opposition from some policymakers and even doctors who don’t like the idea of “rewarding” drug users for not using, Rawson said. Even with political support, it will still require serious time and financial resources to implement.
As the public health system works to scale up contingency management programs, we should be doing more to advance medication-assisted treatment. Success is typically measured by whether patients fully abstain from using drugs. But some experts told me they think that’s misguided.
“The only benchmark right now for getting a treatment approved is whether people stop using for a sustained period at the end of the trial,” said Karla Wagner, a behavioral scientist at the University of Nevada Reno. “But those medications do produce some meaningful impacts on other outcomes that are not abstinence-based.” For example, some clinical trials that involved using a prescription drug to manage cocaine or methamphetamine addiction found that a subset of people do feel fewer cravings and engage in less risky behavior, even if they didn’t always completely hold off on taking narcotics.
“All of those things can be really meaningful and impactful and improve quality of life,” Wagner said.
She took heart in a blog post last year from the director of the National Institute on Drug Abuse, which argued for considering measures other than abstinence when evaluating medications for substance abuse. And the American Society for Addiction Medicine has endorsed the off-label use of stimulant medications that have shown some effectiveness in managing cocaine and meth dependency.
What everyone should know about the rise in stimulant use
Finding a Narcan-like solution that can stop cocaine and meth overdoses once they start is a problem for medical science. But more public knowledge about the symptoms of a stimulant overdose and what to do if you’re with someone who’s experiencing them could still help avert the worst outcomes.
These are the signs to be alert to, according to the experts I spoke with:
- Heart palpitations
- Rise in body temperature
- Erratic behavior, including hallucinations
- Sensitivity to light and sound
If you’re with someone who experiences these symptoms, there are things you can do to help, said Pia Marcus, director of overdose prevention at OnPoint NYC. First, she said, if it’s someone you know well, try to calm them down. Turn off the lights or any sources of sound to create a more peaceful environment. She said you should also try to physically cool them, and recommended ice or ice packs to do that.
“You have to rely on soothing mechanisms to help ground this person,” Marcus said. “It’s a person that’s not necessarily rooted in space and time, and your job is to try to root them.”
It is possible to bring somebody back from danger with these interventions in a community setting, Marcus said. But if these measures don’t appear to be working, the person seems to be having a cardiac event, or if it’s not someone you know well and you don’t feel capable of soothing them, you should call for emergency medical care.
The lesson of the falling opioid death count is that public health interventions can make a real difference. Now is our moment to try to use a similar playbook to get ahead of the cocaine and meth crisis before it gets any worse.
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