Drug Overdose Deaths Involving Cocaine and Psychostimulants With Abuse Potential — United States, 2003–2017

Mbabazi Kariisa, PhD; Lawrence Scholl, PhD; Nana Wilson, PhD; Puja Seth, PhD; Brooke Hoots, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(17):388-395. 

In This Article

Discussion

Deaths involving cocaine and psychostimulants have increased in the United States in recent years; among 70,237 drug overdose deaths in 2017, nearly a third (23,139 [32.9%]) involved cocaine, psychostimulants, or both. From 2016 to 2017, death rates involving cocaine and psychostimulants each increased by approximately one third, and increases occurred across all demographic groups, Census regions, and in several states. In 2017, nearly three fourths of cocaine-involved and roughly one half of psychostimulant-involved overdose deaths, respectively, involved at least one opioid. After initially peaking in 2006, trends in overall cocaine-involved death rates declined through 2012, when they began to rise again. The 2006–2012 decrease paralleled a decline in cocaine supply coupled with an increase in cost.¶¶¶ Similar patterns in death rates involving both cocaine and opioids were observed, with increases for cocaine- and synthetic opioid-involved deaths occurring from 2012 to 2017. From 2010 to 2017, increasing rates of deaths involving psychostimulants occurred and persisted even in the absence of opioids. Drug overdoses continue to evolve along with emerging threats, changes in the drug supply, mixing of substances with or without the user's knowledge, and polysubstance use.[3–8] In addition, the availability of psychostimulants, particularly methamphetamine, appears to be increasing across most regions.**** In 2017, among drug products obtained by law enforcement that were submitted for laboratory testing, methamphetamine and cocaine were the most and third most frequently identified drugs, respectively.†††† Previous studies also found that heroin and synthetic opioids (e.g., illicitly-manufactured fentanyl) have contributed to increases in stimulant-involved deaths.[3,9,10] Current findings further support that increases in stimulant-involved deaths are part of a growing polysubstance landscape. Although synthetic opioids appear to be driving much of the increase in cocaine-involved deaths, increases in psychostimulant-involved deaths have occurred largely without opioid co-involvement; however, recent data suggest increasing synthetic opioid involvement in these deaths.

The findings in this report are subject to at least four limitations. First, at autopsy, substances tested for and circumstances under which tests are performed vary by time and jurisdiction. Therefore, recent improvements in toxicologic testing might account for some reported increases. Second, 15% and 12% of death certificates in 2016 and 2017, respectively, did not include mention of specific drugs involved. The percentage of death certificates with at least one drug specified varied widely by state, ranging from 54.7% to 99.3% in 2017, limiting comparisons across states. Third, potential racial misclassification might lead to underestimates for certain groups, primarily AI/AN and A/PI.§§§§ Finally, certain trend analyses were limited, given small numbers of deaths and the inability to calculate stable rates among some stimulant-opioid drug combinations before 2003.

Preliminary 2018 data indicate continued increases in drug overdose deaths.¶¶¶¶ The rise in deaths involving cocaine and psychostimulants and the continuing evolution of the drug landscape indicate a need for a rapid, multifaceted, and broad approach that includes more timely and comprehensive surveillance efforts to inform tailored and effective prevention and response strategies. CDC currently funds 45 states and DC for opioid surveillance***** and/or prevention activities.††††† The contribution of opioids to increases in stimulant-involved overdose deaths underscores the importance of continued opioid overdose surveillance and prevention measures, including existing efforts to expand naloxone availability to persons at risk for drug overdose. CDC is expanding drug overdose surveillance efforts to include stimulants and is implementing multiple, evidence-based opioid prevention efforts, such as enhancing linkage to care, building state and local capacity, and public health/public safety collaborations.§§§§§ Because some stimulant deaths are also increasing without opioid co-involvement, prevention and response strategies need to evolve accordingly. Increased efforts are required to identify and improve access to care for persons using stimulants, implement upstream prevention efforts focusing on shared risk and protective factors that address substance use/misuse, and improve risk reduction messaging (e.g., not using alone). Continued collaborations among public health, public safety, and community partners are critical to understanding the local illicit drug supply and reducing risk as well as linking persons to medication-assisted treatment and risk-reduction services.

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