By Mark Gold, MD
At the center of America’s deadly opioid epidemic, non-pharmaceutical fentanyl appears to be finding its way into illegal stimulants that are sold on the street, such as cocaine. Adulteration with fentanyl is considered a key reason why cocaine’s death toll is escalating. Cocaine and fentanyl are proving to be a lethal combination - cocaine-related death rates have increased according to national survey data. This has important emergency response and harm reduction implications as well—naloxone might reverse such overdoses if administered in time. A recent study by Nolan et. al. assessed the role of opioids, particularly fentanyl, in the increase in cocaine-involved overdose deaths from 2015 to 2016 and found these substances to account for most of this increase.
Fentanyl and Cocaine
Fentanyl is a synthetic, short-acting opioid that is 50 to 100 times more powerful than morphine and increasingly associated with a heightened risk of fatal overdose. The combination of heroin and cocaine, also known as “speedballing,” was popular in the 1970s. Recently, there has been an uptick in cocaine being adulterated with other powerful substances like the synthetic opioid fentanyl. Unlike in the intentional combination of cocaine with other substances in the 70s, many modern users are not aware that their cocaine may be mixed with another substance, leaving them vulnerable to an accidental overdose.
Cocaine deaths have moved up to the second most common substance present in fatal overdoses—after opioids. Before 2015, fentanyl was involved in fewer than 5% of all overdose deaths each year. This rate increased to 16% in 2015 and continues to rise. At the beginning of 2016, 37% of cocaine-related overdose deaths in New York City involved fentanyl. By the end of the year, fentanyl was involved in almost half of all overdose deaths in NYC. Since then, several US cities have reported similar outbreaks of overdose fatalities involving fentanyl combined with heroin or cocaine. The combination of fentanyl and cocaine has been a considerable driver of the rising death toll since 2015, and opioid-naive cocaine users are at an especially high risk of unintentional opioid overdose.
Why is Fentanyl Appearing in Cocaine?
One theory is that the adulteration is an accident and occurs by residual fentanyl being present in the same space and on the same surfaces where cocaine is being processed. Another theory is that the increasing presence of fentanyl in cocaine concerns cost and supply. Drug cartels can add other cheaper drugs and medications as fillers to stretch out their product.1 By adding fentanyl they may also be producing a more potent and addictive product to expand their market. This, however, is risky since even a small amount of fentanyl can result in death. The Drug Enforcement Agency (DEA) explains that even 2 milligrams of fentanyl, about the size of a grain of rice, can be deadly to an adult. In light of that fact, it’s distinctly possible that street-level illicit drug dealers do not have insight into the contents of their product and are unknowingly selling cocaine adulterated with fentanyl.
Data in this study was acquired from death certificates from the New York City Bureau of Vital Statistics and toxicology results from the New York City Office of the Chief Medical Examiner. Age-adjusted rates per 100,000 residents were calculated for 6-month intervals from 2010 to 2016.
Results suggested that individuals using cocaine in New York City were vulnerable to a greater risk of a fatal overdose due to the increasing presence of fentanyl in the city’s drug supply. In fact, 90% of the increase in cocaine overdose fatalities from 2010 to 2016 also involved fentanyl.
Public Health Challenges
This study highlighted some public health challenges caused by fentanyl-adulterated cocaine:
First responders and those present at the scene of a cocaine overdose may consider administering Naloxone even if the patient denied using opioids.
Fentanyl is very dangerous and powerful and dramatically increases the risk of lethal overdose.
Opioid-naïve individuals that have been using fentanyl-free cocaine lack a potentially life-saving tolerance for opioids. Adding fentanyl to their drug of choice puts this group at an even higher risk of fatal overdose.
Opioid-naïve cocaine users are typically not targeted by current harm reduction strategies and public messages concerning opioid overdose. A lack of education and access to critical resources, including naloxone —the lifesaving overdose reversal drug— render this population more vulnerable to a fatal overdose.
Looking to the Future
As the issue continues to get worse — 19,000 of the 42,000 reported opioid overdose deaths in 2016 were related to fentanyl — the authors of the study emphasize the importance of overdose prevention intervention for cocaine users, with a strong emphasis on access to naloxone and information about fentanyl.
Future prevention efforts must be widened to include cocaine users, especially those who are opioid-naïve, to prevent more fatal overdoses. Cocaine overdose awareness, treatment for dependence, and relapse prevention must be prioritized in a comprehensive response to addiction that puts us on a better path forward and ensures that this country does not repeat past mistakes by implementing substance-centric policy and education efforts.
Nolan, M. L., Shamasunder, S., Colon-Berezin, C., Kunins, H. V., & Paone, D. (2019). Increased presence of fentanyl in cocaine-involved fatal overdoses: implications for prevention. Journal of Urban Health, 1-6.
Drug Enforcement Administration. (2018) Cocaine/Fentanyl Combination in Pennsylvania. (Feb, 2018) DEA Bulletin. Retrieved from https://www.dea.gov/sites/default/files/2018-07/BUL-061-18%20Cocaine%20Fentanyl%20Combination%20in%20Pennsylvania%20--%20UNCLASSIFIED.PDF
Srivastava, B. A., & Gold, M. S. (2019, January 18). Adulterants in opioids are the rule: Implications for clinical care. Retrieved from https://www.mdedge.com/psychiatry/article/164315/addiction-medicine/adulterants-opioids-are-rule-implications-clinical-care/page/0/1Subscribe
Dr. Mark S. Gold is a teacher of the year, translati