The Role of Cocaine Mortality in a Resurgent Overdose Epidemic

In 2018, there was a downturn observed in overdose mortality. Recent preliminary mortality data released by the Centers for Disease Control and Prevention (CDC) for 2019 and the first quarter of 2020 suggest, however, that 2018 was not the beginning of a sustained trend. In the US, drug overdose deaths are predicted to have risen by 4.8 percent compared to the number of overdose deaths in 2018. This increase has been driven disproportionately by the only three drugs that also did not see declines in mortality in 2018—methamphetamine, cocaine, and fentanyl.

In our previous analysis of the 2018 mortality data we identified that both methamphetamine and cocaine had contributed to more deaths overall in the US than in previous years and were increasingly associated with deaths in states and cities where they had not traditionally had a strong footprint. Both drugs have had past deadly epidemics, meth in the 2000s and cocaine (specifically crack-cocaine) in the 1980s and early 1990s, but both of the new epidemics are resurgent in different ways than before.

We previously examined the increase in methamphetamine; in this companion research we unpack the recent increase in cocaine mortality, how it differs from the previous crack-cocaine epidemic, and how it has contributed to reversing the 2018 decline in overdose mortality. While cocaine-only mortality has increased, the majority of the increase in cocaine mortality has been driven by mixtures of cocaine and the synthetic opioid fentanyl. Unlike the 1980s when the increase in cocaine use was driven entirely by single-drug dealers selling only crack-cocaine, modern dealers tend to sell and process multiple drugs leading cocaine to be adulterated with fentanyl accidentally or on purpose as a “super speedball.”

The majority of cocaine-related overdoses also involved opioids by 2017, ranging from a low of 68 percent in Washington DC to a high of 86 percent in Massachusetts.

Cocaine Production, Sale, and Use

Cocaine is a drug produced from coca leaves which have been used as a natural stimulant, like tea or coffee, and to treat the effects of high altitude for thousands of years in South America. Cocaine—specifically the chemical cocaine hydrochloride—was developed initially as a medication in the early 1900s. Cocaine acts on the brain by binding to the dopamine transporter and blocking the removal of dopamine from the synapse where it then accumulates, resulting in an amplified euphoric feeling. Long-term use can dramatically change the way the brain’s reward system works and how brain pathways respond to stress. Physical effects include increased blood pressure and heart rate, insomnia, lack of appetite, paranoia, depression, and, in the extreme, cardiac arrest, stroke, and death.

Cocaine is currently ingested in two forms—powder cocaine, which is water-soluble hydrochloride salt, and base cocaine (also called rock cocaine or crack-cocaine), which is water insoluble after processing with ammonia or baking soda and water. Base cocaine is smoked and powder cocaine is injected or snorted. The effect of cocaine on the brain is determined by the dose and the method of ingestion. Smoking and injecting cocaine can result in an immediate euphoric “rush” high, whereas snorting cocaine has a less intense but longer lasting effect. Cocaine tolerance develops rapidly so users require higher doses each time for the same effect. Cocaine is a Schedule II drug in the US meaning it has high potential for abuse with severe psychological or physical dependence, but also has medical uses.

Similar to the methamphetamine pills that have started to show up disguised as MDMA (also known as molly and ecstasy), cocaine has also begun to show up in pill form although to a lesser extent. These pills appear like prescription pills rather than MDMA or party drug tablets. This may be an attempt to capitalize on the illegal market for prescription stimulants like Adderall.

All coca leaves, the base component of cocaine, are grown in Colombia, Peru, and Bolivia with the highest levels of cultivation and initial production in Colombia. Cocaine requires a number of precursor chemicals which are highly regulated, much like the precursor chemicals to methamphetamine. Cocaine generally enters the US through land crossings with Mexico, hidden among legal imports, and is also regularly trafficked by sea directly from Colombia or through Caribbean nations.

Cocaine prices were on the decline and purity was on the increase prior to the COVID-19 pandemic. This decline in price and increase in purity is in part due to heightened levels of coca production. Due to the pandemic disrupting cross border traffic in both finished cocaine and precursor chemicals, this trend has been interrupted. There has recently been a decline in both cocaine imports and production which has led to an increase in cocaine prices, but a decrease in the prices for coca leaves due to a glut of coca leaf supply and lowered demand for the raw leaves, which could have long run effects on cocaine production if farmers shift away from cultivation. Despite the decline in cross boarder traffic due to the pandemic, cocaine is still entering the US. For example, 1300 pounds of cocaine were seized from a sophisticated new tunnel near San Diego this year.

Legacy of the Crack-Cocaine Epidemic

It can be difficult to track the crack-cocaine epidemic of the 1980s and early 1990s because specific drug reporting in overdose deaths was uncommon and the reporting and surveillance systems that we rely on now for tracking drugs were developed in part in response to the more current crisis. Researchers have used a number of indicators to track crack’s spread including cocaine arrests, cocaine emergency room visits, frequency of newspaper mentions, cocaine-related deaths, positive cocaine tests among arrestees, and US Drug Enforcement Administration (DEA) seizures. Using an index of these measures crack-cocaine’s use sharply rose from 1985 to 1989 and then fell. Use was concentrated in central cities including Newark, San Francisco, Philadelphia, Atlanta, and New York.

Crack-cocaine was heavily associated with violence in the 1980s and researchers have directly linked the introduction of crack-cocaine into cities to increases in the homicide rate, decreases in educational attainment, increases in crime, and increases in negative birth outcomes. The effects were felt most strongly for young Black men ages 14-24 whose homicide rate nearly doubled from 1984 to 1994, while the homicide rate for Black men 25 and older was flat. By 2000, the homicide rate had fallen below 1980s levels. At the same time as the increase in homicides there was an increase in fetal deaths, low birth weight, weapons arrests, and the fraction of children in foster care for Black Americans.

Crack-cocaine, as opposed to powder cocaine, heroin, and other drugs, was an ideal commodity for organized street gangs as it could be sold in small quantities in anonymous markets for low prices without the infrastructure of scales and distribution networks. Organized street gangs generally have city-wide, multi-tiered leadership with the primary economic purpose of selling drugs as opposed to less-organized, small neighborhood social gangs that engage in crime as a secondary enterprise. Much of the increase in violence during that time is attributed to these larger organized gangs fighting over distribution territory.

In the 1980s the DEA, police, and policymakers saw crack-cocaine as more dangerous than powdered cocaine and linked it to a rise in urban crime and gang violence in the 1980s. Policymakers attempted to fight this “crack epidemic” with extreme criminal penalties. The “war on drugs” was energized by the increase in crack-cocaine use and associated violence and resulted in the Violent Crime Control and Law Enforcement act of 1994, more commonly known as the 1994 Crime Bill. Crack-cocaine was subject to a 100-to-1 quantity ratio to powder cocaine, meaning that being arrested with 1 gram of crack-cocaine was equivalent to being arrested with 100 grams of powder cocaine. The fair sentencing act of 2010 (FSA) reduced this multiplier to 18-to-1. The United States Sentencing Commission estimates this change resulted in a reduction of 29,653 bed-years in the Federal prison system over a three year period. This means people convicted of cocaine offenses are expected to spend 29,653 fewer years physically in prison.

Signs of a Renewed, but Different, Overdose Epidemic

Overdose mortality has been on the increase in the US for the past 20 years, driven primarily by prescription opioids and later, as those became better regulated, heroin. In the mid-2010s deaths from heroin and prescription opioids alone became eclipsed by synthetic opioids, most notably fentanyl, which is lethal in much smaller doses than either heroin or prescription opioids.

Just like the rise in mortality, the decline in 2018 was also driven almost entirely by a decline in mortality due to opioids—specifically prescription opioids like OxyContin and the street drug heroin—and a reduction in the rate of increase in deaths involving fentanyl and similar highly potent synthetic opioids. From 2017 to 2018 all opioid deaths fell by 4 percent even though fentanyl deaths increased by 10 percent, down from the 47 percent increase from 2016 to 2017 and 103 percent increase from 2015 to 2016. Cocaine deaths, in contrast, were up 5 percent in 2018 and methamphetamine deaths were up 10 percent.

The provisional data for 2019 and 2020 unfortunately negates those decreases in 2018. If the 71,966 overdose deaths predicted for 2019 hold, they will have set a new record for most overdose deaths in a year, above the previous high of 70,237 in 2017. Much of this is attributed to a continued increase in cocaine and fentanyl mortality. Cocaine mortality is predicted to have increased by a further 8 percent, and fentanyl by 16 percent in 2019.

The preliminary numbers for 2020 in the early days of the pandemic are even bleaker. Although exact counts for those months have not yet been released, we can compare the year ending in March 2020 with the year ending in March 2019. Comparing those two years, cocaine mortality is up 15 percent with 17,418 deaths in the year ending in March 2020. When we compare those numbers to the last official mortality data calendar year (January to December) 2018, the predicted increase jumps to 19 percent over the past two years.

Preliminary Overdose Death Data, 2018 – 2020

* Year ending in March.

SOURCE: National Center for Health Statistics, 2020, https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm#data-tables.

The preliminary data are not detailed enough to determine drug combination deaths, so we do not know if this increase in cocaine mortality is driven by an increase in cocaine-only mortality or cocaine in combination with fentanyl which drove the 2018 increase. However, there is a strong correlation (0.85) between a state’s cocaine mortality rate and fentanyl morality rate.

Only 15 states are estimated to have had a decrease in overall overdose mortality in 2019. Those states include Maryland, Massachusetts, New Jersey, and Rhode Island, each of which would remain above the previously unprecedented rate of 10 deaths in 100,000.

Of states that have reported drug-specific 2020 data, only four predict a reduction in cocaine overdose mortality. Eleven of the 15 states that did not report cocaine-specific mortality rates reported an increase in overall overdose mortality.

Strikingly, the states that have recently spiked in terms of cocaine mortality are almost an even split between states that had some of the most severe crack-cocaine incidence in the 1980s and states that have more recently been affected by the opioid epidemic.

Lessons from 2018 on the Geography and Demography of Cocaine Mortality

Who is most affected by cocaine overdoses?

The detailed mortality data from 2018 provides insight into the role fentanyl plays in the increase in cocaine mortality. In 2014 there were 5,415 cocaine overdose deaths and 11 percent of those also involved fentanyl. By 2018 that number had skyrocketed to 14,666 and nearly 60 percent involved fentanyl. Until 2010 only half of cocaine overdoses also involved opioids, by 2018 nearly 75 percent do.

Opioid Involvement in Cocaine Overdose Deaths

SOURCE: US Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Multiple Cause of Death 1999-2018 on CDC WONDER Online Database, released 2020. Compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program: https://wonder.cdc.gov/mcd-icd10.html.

Cocaine overdoses are much more common for Black Americans than any other race or ethnicity. Over the past 10 years (2009-2018), 38 percent of Black overdose deaths have involved cocaine compared to only 12 percent of white overdose deaths. However, white people who die from overdoses involving cocaine are far more likely to have used cocaine in combination with opioids than Black people. Over one third (35 percent) of white cocaine overdoses also involve an opioid compared to less than a quarter (24 percent) of Black cocaine overdoses. The 2018 numbers diverge even more by race. White overdose deaths are less likely to involve cocaine than Black overdose deaths. Only 18 percent of white overdose deaths involved cocaine compared to 43 percent of Black overdose deaths and 63 percent of those white cocaine overdose deaths also involved fentanyl compared to 49 percent of Black cocaine overdose deaths. Overdose deaths map to drug use. Cocaine use data reflects that users are more likely to be Black than white people, but that white people who use cocaine are more likely to use it in potentially lethal combination with fentanyl.

Since 2014 the largest increase in deaths has been for adults over 65. There has been nearly a 250 percent increase in deaths involving cocaine and a 45 percent increase in deaths involving both cocaine and fentanyl. Other age groups had lower rates of increase but still above 140 percent increase in cocaine deaths and 12 percent increase in fentanyl and cocaine deaths.

The largest increase for a racial or ethnic group was for Hispanic people whose cocaine mortality rose 220 percent compared to 180 percent for Black, Asian, and Native Americans. This increase was driven by a 21 percent increase in fentanyl and cocaine deaths for Hispanic Americans.

Men are more likely to die from a cocaine overdose than women and the ratio has remained stable over time with women making up only 30 percent of cocaine overdose deaths. This gender difference in mortality is roughly equivalent to gender differences in use from the 2019 National Survey on Drug Use and Health in which 28 percent of people who reported using cocaine in the previous year were women.

People who die from cocaine overdoses also tend to have substantially lower educational attainment than the general population. In 2018, 74 percent of people 25 and older who died of a cocaine overdose had a high school diploma or less compared to only 38 percent of the general population 25 and above. Strikingly, 21 percent of those who died of a cocaine overdose do not have a high school degree at all compared to less than 10 percent of the general population.

While cocaine mortality is highest among low-income people with less education, there has also been an uptick in cocaine use on college campuses. College students report having a more favorable perception of cocaine, compared to other drugs. Researchers speculate that this may be due to two main factors, less negative reporting on cocaine compared to opioids, and the rise in both the legitimate medical use and the abuse of prescription stimulant drugs like Adderall.

Geography

Much like methamphetamine, the current wave of cocaine mortality has begun to move into non-traditional markets, as shown in our Overdose Mortality Dashboard. Cocaine has a long and sustained history as a party drug, but had fallen out of favor as the prime drug of abuse by 2000, largely replaced with opioids and methamphetamine. Crack-cocaine and powder cocaine maintained a presence in the Northeast and a handful of Midwestern and Southeastern cities.

From 1999 to 2014 only two places, Washington DC and New Mexico, consistently had cocaine overdose rates above the problematic rate of 5 in 100,000 and another three states, Rhode Island, Massachusetts, and Louisiana, occasionally reached this level. Cocaine overdoses began to increase nationally and spread to more states in 2014, with Ohio, Rhode Island, and Massachusetts all beginning to consistently have overdose rates over 5 in 100,000. By 2017, 18 states were above 5 deaths and 7 were above 10 deaths in 100,000. Those above 10 deaths in 100,000 included both the traditional cocaine hotspot of Washington DC, and the opioid hotspots West Virginia, Ohio, and Pennsylvania. Much of this increase in mortality was driven by the increased lethality of mixing cocaine and opioids. The majority of cocaine-related overdoses also involved opioids by 2017, ranging from a low of 68 percent in Washington DC to a high of 86 percent in Massachusetts.

Preliminary data for 2019 and part of 2020, the 12 month period ending in March 2020, predicts an even sharper increase in cocaine mortality. For the first time Washington D.C. is expected to post a cocaine mortality rate above the unprecedented rate of 20 deaths per 100,000 with Delaware close behind with 17 per 100,000 expected. For Washington, D.C. this is a cocaine mortality rate more than 4 times greater than the already problematic rate of 5 per 100,000 the city experienced at the turn of the millennium. This preliminary data is not detailed enough to determine if these deaths are attributed to cocaine only or in combination with fentanyl. Of the states with cocaine deaths over 10 in 100,000 in 2018, only one, West Virginia, is predicted to bring their numbers down. In fact, only 4 states are predicted to have a decline in cocaine mortality.

States with a shorter history of elevated cocaine overdoses tend to have a larger percentage of recent cocaine overdoses attributed to both cocaine and an opioid, generally fentanyl. While some of this mixing may be intentional (e.g., “super speedball”), it is likely that a substantial percentage is not, according to the DEA. Unlike the 1980s when crack-cocaine was a single commodity for dealers, modern dealers generally sell multiple types of drugs which can be mixed in the adulteration process. Mixing fentanyl or other opioids into cocaine is particularly dangerous because habitual cocaine users may not be aware of the procedures for reversing a fatal opioid overdose and are unlikely to have naloxone (a medication that can stop and reverse a lethal overdose) on hand. As this phenomenon increases, dealers have even been charged and convicted in some states for manslaughter for selling adulterated cocaine.

Treatment and Policy Responses

There is no medication available to treat cocaine overdoses or cocaine addiction. Like meth, overdose symptoms can be treated with a sedative but the frequency with which cocaine is mixed with fentanyl can make that a risky proposition because sedatives magnify the effects of opioids and can slow breathing resulting in oxygen deprivation to the brain and death. Cocaine overdoses that involve fentanyl or other opioids can be treated with naloxone which reverses the opioid overdose and may prevent death.

There are also no medication treatments to prevent cocaine relapses for those in the process of addiction recovery. Methadone, buprenorphine, and naloxone are drugs that have had success in assisting people recovering from opioid addiction to abstain by minimizing withdrawal symptoms but there is no comparable drug for stimulants like cocaine. People with cocaine and opioid substance-use disorders may benefit from these medical treatments, but they may still crave cocaine. Most commonly buprenorphine is prescribed in combination with naloxone which both mitigates withdrawal effects and inhibits the positive effects of opioids so if a person relapses, they will not actually get high. However, if the relapse involves cocaine, naloxone would have no effect in inhibiting the effect of cocaine.

It is crucial to maintain and expand the addiction treatment systems developed over the past 20 years of the opioid epidemic and to adapt treatment for the increased presence of poly-drug users, specifically those who use both stimulants and opioids.

There are also fewer harm reduction strategies for cocaine, much like methamphetamine, because injection is not the most common form of use. Clean needle exchanges and naloxone that have curbed deaths and related illnesses in opioid users would have minimal benefits for cocaine. Also, like meth, the energy and euphoria of the drug can lead to risky behaviors resulting in other illnesses and health problems which are harder to mitigate.

As such, cocaine addiction treatment has focused on abstinence and support. Twelve step programs and cognitive behavioral therapy (CBT) are the most common treatment programs. There is some evidence that drugs used to treat alcohol addiction may also aid in treating cocaine addiction. Research into pharmacological treatments for cocaine continues, with researchers focusing on a “cocaine vaccine” which would be similar to naloxone in that it would block the effect of cocaine in users of the treatment.

One of the most promising existing treatments is contingency management (CM), which provides incentives, sometimes monetary, to people in recovery for continuing to abstain from cocaine, and other drug, use. This treatment is controversial because it essentially pays users to stay clean. Yet, CM is routinely proven successful especially for concurrent users of cocaine and opioids. The combination of CBT and CM appears even more effective long term than either treatment alone. One of the few places actively providing CM is the Veteran’s Administration, which has found success with the treatment.

Supply-side policy responses such as destroying coca fields have had, at best, only minor success at limiting cocaine production and use. There is some evidence that monetary and moral incentives can encourage farmers to stop coca production, but the evidence is limited. The recent downturn in coca prices is likely to have a larger effect on production—if farmers cannot make money on coca, they will not grow it. Destruction of coca also has negative effects on the surrounding environment and biodiversity. Coca also has traditional uses, beyond cocaine production, and Bolivia has expanded legal coca farming in recent years.

Beyond limiting coca production, targeting essential “precursor” chemicals is also a valuable tool in limiting cocaine production. Substantial refinement is involved in transforming the natural stimulant coca leaves into potent cocaine. Each kilogram of cocaine requires 450-600 kilograms of coca leaves. Various chemical controls have been put in place since the late 1980s and have all successfully reduced cocaine production as measured by seizures. Controls placed on sodium permanganate in 2006 reduced seizures by 22 percent, nearly doubled the price, and reduced purity by 35 percent. This is one of the most crucial chemicals in cocaine production.

Conclusions

The preliminary mortality data for 2019 and 2020 suggest that we have not turned a corner in the overdose epidemic and the 2018 drop in overdose mortality was a blip in a continuing overdose epidemic not the beginning of a new trend. The preliminary data predicts that the increased use and lethality of cocaine will continue to devastate individuals and communities and presents a difficult policy challenge. Specific drug epidemics come in waves but the disease of addiction is a constant presence and it is crucial to treat that underlying addiction and associated mental and physical health problems. As we have learned from our Stories from Sullivan series on the opioid epidemic, responding to an overdose epidemic requires holistic, adaptable, and sustained policy responses driven by community need. The current pandemic adds additional hurdles to those treatments by making it difficult to hold Cognitive Behavioral Therapy, Contingency Management, and 12 step meetings in person thus cutting off those in recovery from their support systems. Changes in drug supply chains can also add to the lethality of cocaine by providing users with drugs of different potency, or different adulteration than they are accustomed to. It is crucial to maintain and expand the addiction treatment systems developed over the past 20 years of the opioid epidemic and to adapt treatment for the increased presence of poly-drug users, specifically those who use both stimulants and opioids.

ABOUT THE AUTHOR

Leigh Wedenoja is senior policy analyst at the Rockefeller Institute of Government