On a late October night last year, Elle was on the edge of her bathtub in Holyoke, Massachusetts, passing in and out of consciousness after shooting cocaine.
Cocaine usually gave her an intense, immediate rush. She had experienced its bad effects, too, like anxiety, paranoia, and even hallucinations. But this night was something different.
"It got really scary,” Elle, a nickname, told BuzzFeed News. “I started going out, but then I would peak up. I would be hyperalert, high. My heart would be racing. I would be sweating. And then my breathing would plummet. It would get low and slow."
At some point, she realized what was going on: Her cocaine was laced with fentanyl, a deadly opioid 50 times more potent than heroin.
Elle knew fentanyl. For years she had used heroin and other opioids, including fentanyl when it was available. But she had switched to cocaine a year earlier, after her adult son became addicted to heroin. “I decided I was going to get my ass off the heroin because I wanted to be able to show my son it was possible,” she said. She went to a methadone clinic every day to stave off her opioid withdrawal but also began using cocaine.
Elle got lucky the night of her fentanyl scare. A friend was nearby, ready to dial 911 or administer a nasal spray of naloxone, which reverses opioid overdoses. Many others aren’t so fortunate.
Deaths from cocaine, after holding steady for many years, increased an alarming 52% between 2015 and 2016, according to the CDC, with the trend continuing in the most recent federal data. The stimulant is now killing approximately 13,000 people a year, on track to rival painkiller pills and heroin.
“Something dramatic is going on behind the scenes,” said John Eadie of the National Emerging Threat Initiative of the National HIDTA Assistance Centers, who spoke this month at an overdose crisis summit in Atlanta.
Although researchers don’t fully understand why cocaine overdoses are spiking, they know that one of the biggest drivers is fentanyl. Once an obscure hospital drug, the synthetic opioid has taken over the US illicit drug market in just five years, killing tens of thousands of people including Prince and Tom Petty.
Overdose deaths by drug type
Although some people use fentanyl by itself, most use it — knowingly or unknowingly — in combination with other drugs. When it first hit the US, fentanyl was most often mixed with heroin, driving a surge of heroin deaths. In the last couple of years, it’s spread to other drugs, too.
“We are certainly seeing fentanyl in cocaine, in methamphetamines, in pills, and a lot of other things,” said forensic scientist Michael Rieders of NMS Laboratories in Willow Grove, Pennsylvania, which tests seized drugs for toxic ingredients.
As recently as 2012, fewer than 200 of the cocaine overdoses reported by the CDC involved fentanyl. By 2016, that number increased to more than 4,100 — or about 40% of all cocaine deaths:
Overdoses involving cocaine and synthetic opioids (such as fentanyl)
A BuzzFeed News analysis shows that fentanyl is tainting cocaine through much of the Eastern Seaboard. In at least eight states — notably New Hampshire, Massachusetts, and Maine — the majority of cocaine deaths involve fentanyl. But in other parts of the country, like the West Coast, there appears to be little mixing of the two drugs. (Here's our full methodology, analyses, and data.)
Why fentanyl is creeping into the market for cocaine and meth is a mystery, with a wide range of possible explanations, according to interviews with more than a dozen law enforcement officers, public health officials, scientists, and treatment advocates. Some say it’s just basic economics — a surge in customer demand for stronger drugs and intentional mixing of drugs as speedballs. Others say the culprits are the dealers who surreptitiously want their customers to become more addicted. Or it might just be accidental contamination by kitchen table chemists.
Regardless of why it’s happening, the rise of fentanyl in the cocaine supply seems to be hitting black communities harder than ever before: The death rate from fentanyl-cocaine overdoses is higher for black people than any other racial group.
Some addiction experts worry that if the overdose crisis becomes less associated with white Americans, it could lead a return to the draconian policies of the crack cocaine era, when the government pushed users into prison instead of treatment.
“It’s people of color who are increasingly dying due to fentanyl,” Kathie Kane-Willis of the Chicago Urban League told BuzzFeed News. Cities have had heroin and cocaine problems for decades, she noted, and they still need the kind of help — drug treatment and job assistance — that’s now focused on rural, white communities.
Fentanyl-cocaine overdoses are a huge problem in the Northeast, and many users have no idea.
The proportion of cocaine overdose deaths that also involve fentanyl is increasing dramatically in many states.
In 2016, a synthetic opioid such as fentanyl showed up in more than 83% of the cocaine-related overdoses in New Hampshire; 70% of cocaine-related deaths in Massachusetts; nearly 64% of those in Maine; and 54% of those in Connecticut:
Percent of cocaine-related deaths that involved synthetic opioids such as fentanyl in 2016
In at least eight states, the combination of fentanyl and cocaine is so prevalent, it’s likely responsible for the majority of deaths that involve cocaine:
States where 50%+ of cocaine-related deaths also involved synthetic opioids such as fentanyl in 2016
“In the upper Northeast is really where we find the most fentanyl found in combination with other substances,” DEA supervisory chemist Jill Head told BuzzFeed News.
At the start of 2016 in New York City, for example, 30% of all cocaine-related deaths involved fentanyl but not heroin. By the third quarter of the year, about 50% did. Over a single day last July, Connecticut saw seven overdoses of crack cocaine laced with fentanyl, including one that was fatal. In New Hampshire, deaths from cocaine in combination with an opioid have outnumbered deaths from cocaine alone since 2012, according to data from the Office of the Chief Medical Examiner.
The East Coast is also a hotbed of fentanyl’s chemical cousins. Acetyl fentanyl, the analog that was one of the earliest reported signs of the current epidemic, first turned up in Rhode Island in 2013. The most worrisome of these analogs is carfentanil. Whereas fentanyl by itself is roughly 50 times more potent than heroin, carfentanil is 5,000 times more potent. In Miami-Dade County, Florida, combinations of cocaine and carfentanil killed at least 84 people in 2016 — more than any other city.
These drugs are so deadly not only because of their potency but because of the unpredictability they introduce into the drug supply. As little as 2 milligrams of fentanyl might lead to a fatal overdose, and drug dealers are not often cutting their products with the precision of industrial chemists.
Some drug users have noticed fentanyl’s intrusion into their product. In New York City, according to a recent conference presentation by Denise Paone of the city’s Public Health Department, some users complain of the “chocolate chips” of concentrated fentanyl found in various powdered drugs sold on the street.
But many cocaine users have no idea. “They say, ‘Oh, I thought we were just using cocaine,’” said Christopher Hickey, an emergency medical services officer at the Manchester, New Hampshire fire department. Hickey sees adulterated cocaine in roughly 10% of all the overdose emergencies he responds to, he said. “If that person is a cocaine addict and they’ve never done opiates, it’s going to hit them harder.”
Richard Saitz, an addiction medicine specialist from Boston University, told BuzzFeed News a similar story. “I have seen young people who think they are trying cocaine end up in intensive care and testing positive for cocaine and fentanyl,” he said. “They are surprised.”
Since cocaine is a stimulant and fentanyl a depressant, mistaking the two might be especially dangerous.
“They might take what they think is cocaine and not get the feeling they expect — in fact they get the opposite — and so they think they have to take more to get what they expect,” said Baltimore City Health Commissioner Leana Wen. “Instead they give themselves a fatal overdose of fentanyl.”
In her city, fatal overdoses involving cocaine and fentanyl jumped from 82 deaths in 2014 to more than 400 in just the first nine months of 2017.
No one fully understands why fentanyl is turning up in the cocaine supply. It’s probably many factors, and they vary from one city to the next.
Why fentanyl is turning up in cocaine is a mystery, partly because the CDC’s overdose data does not distinguish between deaths from cocaine laced with fentanyl and those from intentional mixing of the two drugs.
“We are at such a loss,” said Jessica Tilley, who runs a branch of the New England User’s Union, an underground needle exchange in Western Massachusetts that serves about 60 users a month. Her facility has recorded six cases of cocaine-fentanyl overdoses, she said. “We cannot find an answer. And it's scaring the hell out of us.”
Treatment advocates like Tilley tend to believe it’s mostly from accidental contamination, whereas law enforcement officers lean toward deliberate mixing. After two deaths caused by cocaine and fentanyl in Saskatoon, Canada, for example, police there claimed that “profit-driven” drug dealers were adding the fentanyl to create more addicted customers.
Drug dealers might also do this for marketing reasons — to differentiate their product from competitors.“Everyone wants to say, ‘My stuff is special,’” said Rieders of NMS Laboratories.
Yet others say it’s the users who are mixing fentanyl and cocaine. “People are putting them together — on purpose,” said Marcella Sorg, a researcher at the Drug and Alcohol Research Program at the University of Maine. When drugs are seized by authorities in her state, she said, they tend to be baggies of cocaine or fentanyl, but not mixtures of the two. “I think this is an end-user phenomenon in Maine, anyway.”
Although speedballs have historically been made of heroin and cocaine, that’s changing as fentanyl becomes more widespread. “The most likely answer looking at this is fentanyl is becoming more common as it substitutes for heroin,” medical epidemiologist Dan Ciccarone of the University of California, San Francisco, told BuzzFeed News.
Tino Fuentes, a treatment advocate who has tested street drugs for fentanyl in cities along the East Coast, said its appearance in bags of cocaine seems to come at random. That, he argued, suggests incidental contamination rather than deliberate mixing by dealers. “It’s not like they are sterilizing the tables where they are cutting drugs,” he said. “Most of the dealers I talk to don’t even know it is in their stuff.”
And all of these things could be happening at once. Along with speedball users overdosing on fentanyl they thought was heroin, Fuentes suspects that some low-level drug dealers — “knuckleheads just trying to make some money fast” — might occasionally mix fentanyl with cocaine, thinking it will deliver a unique high and help stretch out cocaine sold to recreational users. “But I don’t see the people at the top doing this — nobody wants to kill their customers.”
Adding to the complexity, not every community in every city is seeing fentanyl in cocaine. “We haven't heard a lot of our current clients talking about overdosing on fentanyl-laced cocaine,” Cyndee Clay of the nonprofit organization Helping Individual Prostitutes Survive (HIPS), which offers health services to sex workers in Washington, DC, told BuzzFeed News. “It's just not our population at the moment, or it hasn't hit here yet.”
In 2016, 46% of cocaine deaths in Washington, DC, involved a synthetic opioid, according to the CDC, but that could be driven by intentional mixing of cocaine and fentanyl or cocaine and fentanyl-laced heroin.
So far, the one drug that seems free of fentanyl contamination is marijuana, according to DEA drug seizure data. The DEA’s John Halpin cautioned the agency’s data was “patchy,” though, focused mostly on seizures from larger cases and lacking granularity in local drug markets. “The trouble is we can’t be everywhere.”
Overdose rates are highest among white people, but they’re rising fastest in the black community.
Between 2015 and 2016, the latest available years for CDC data, overdose deaths climbed for all races, but especially for people of color. White people in 2016 had the highest fatal overdose rate at 25 per 100,000 people, a 20% increase from the year before. But the increase was nearly 24% for Latino populations and 40% for black people.
These numbers could get even worse as fentanyl infiltrates supplies of cocaine, which has been popular in black communities since the crack epidemic of the 1980s washed over major cities.
In the 2009 book Righteous Dopefiend, a decadelong study of homeless drug users in San Francisco, Philippe Bourgois and Jeff Schonberg documented a split between white and black drug users, with the latter preferring speedballs. A similar pattern has been widely seen in other cities, with Mexican American, Puerto Rican, and black users more often injecting mixtures of drugs.
In 2016, the latest available year, black people died from a combination of cocaine and fentanyl at a rate of nearly 1.9 for every 100,000 — more than any other racial group.
An increase in deaths from fentanyl-laced cocaine is particularly worrisome because the stigma surrounding some forms of cocaine, particularly crack, could make it harder to get people into treatment.
“When we do talk to people who use crack, we have to talk to them, like, away from other people because they are so scared of people knowing they smoke,” one health worker told Paone’s team at the New York City Health Department last year in an anonymous survey. “The stigma is worse than heroin use.”
Some experts are worried that law enforcement will repeat the mistakes of the crack cocaine era, bringing heavier sentences for fentanyl than other drugs. The Justice Department supports more jail time for dealers who sell drugs containing fentanyl, for example, adding six months to the current six and a half year recommended sentence for selling a gram of fentanyl. Such weight-based sentences might incentivize dealers to turn to more potent drugs such as carfentanil, which weigh less but are even more deadly, said Dennis Cauchon of Harm Reduction Ohio, which monitors overdose trends.
A recent Pew Charitable Trust analysis of prison and public data, meanwhile, shows there is no statistically significant link between imprisonment rates and either illicit drug use or overdose deaths.
With more cocaine coming into the US from South America, the fentanyl problem is likely to get worse.
Good weather and a peace deal in Colombia means the US is due for more imports of cocaine. The South American country — the source of most US cocaine — reported an unexpectedly high yield for coca last year, the second bumper crop in a row. The street price of a gram of cocaine dropped from $220 in 2014 to $156 in 2016, according to the DEA, and will continue to drop as more supply rolls in.
And although people are already dying of cocaine-fentanyl combinations in alarming numbers, much of the cocaine supply does not have fentanyl in it — yet. (A recent NYPD analysis of more than 3,000 seized cocaine samples, for example, showed that only 1% contained fentanyl.) That means there’s still a lot of potential for more fentanyl to spread through the illicit drug supply.
“We need more and better monitoring” of illicit drugs, Paone said. But analyzing street drugs for their chemical makeup is very expensive: Testing a single syringe for fentanyl and other drugs costs about $300, and public health departments are famously strapped for funding. Wider distribution of inexpensive fentanyl test strips to drug users might help.
Nearly 1.5 million adults use cocaine every month in the US. That’s almost three times higher than the estimated number of people with a heroin use disorder. With the price of cocaine dropping and supply expanding, an increase in cocaine use would come at exactly the wrong time, triggering a new phase of the overdose crisis.
“Once again we are not paying attention,” said Eadie. “What we are seeing in opioid epidemics, those are depressants, and people might start looking for stimulants to get out of their depression.” ●
In 2016, fatal cocaine overdoses involving fentanyl but not heroin rose to 50% in New York City. An earlier version of this story said it rose to 90%.