Scottie McDonald III has struggled with substance abuse for years and knows he constantly risks his life.
He uses cocaine almost every day and sometimes uses it in combination with fentanyl, so deadly a tiny amount can kill a person. He carries around Narcan, a brand of the overdose reversal drug naloxone, because he has seen friends overdose, though he hasn’t.
“Even though I’m struggling, I take precautions,” McDonald said. “Even though I have a suicidal lifestyle, it doesn’t mean I want to die.”
Others haven’t been as lucky as McDonald. There has been a rapid increase in cocaine-related overdoses in Maryland, and often the stimulant is found in combination with opioids, either due to cocaine tainted with opioids or deliberate co-use, according to experts.
According to annual reports from the Vital Statistics Administration of the Maryland Health Department, cocaine-related deaths began to rise in 2014 and increased significantly between 2015 through 2018 — around 303%. That increase has slowed in recent years, but is still of concern to some experts.
As heroin supplies in many U.S. cities have diminished, and fentanyl — a drug up to 50 times stronger — has become more pervasive, fatal fentanyl-related overdoses have risen rapidly across the country, during what has been called the deadliest drug crisis in American history. Maryland has seen a significant increase in fentanyl-related deaths, which reached a 10-year high in 2020. The synthetic opioid has also contributed to a rise in deaths related to cocaine.
In 2019, cocaine-related deaths saw a 2% decrease in Maryland, which mirrored broader overdose trends, according to the Opioid Operational Command Center (OOCC). Numbers increased again in 2020 — by 6% — likely due, at least in part, to the COVID-19 pandemic.
Social distancing led more people to use drugs in isolation, and to have “more limited access to and utilization of critical community resources and support networks,” according to a study published in 2022. The pandemic also increased stress and anxiety, as well as other risks associated with a rise in drug use, the study said.
Cocaine-related deaths again appear to have risen in 2021, though the data is still preliminary and could change. Numbers appear to be decreasing again within around the last six months of reported preliminary data through August 2022, according to numbers provided by the OOCC.
Despite these fluctuations, current levels of fatal cocaine-related overdoses are significantly higher than even just around 10 years ago. In 2012, for example, there were 153 cocaine-related deaths in Maryland. In 2015, there were 221. And in 2020, there were 921. In 2021, preliminary numbers indicate there were around 1,022 — a more than 500% increase since 2012.
The rise in cocaine-related deaths can largely be attributed to opioids, rather than to cocaine use alone, according to experts and annual state reports.
In 2020, more than 90% of cocaine-related deaths occurred in combination with fentanyl, according to the latest annual state health department report. In 2019, that number was 85%, and in 2018, it was 82%. Cocaine-related deaths also occurred in combination with other substances, but were less common.
Only 67 of 921 cocaine-related deaths in 2020, according to state data, were overdoses not in combination with opioids.
“I never saw somebody just overdose on cocaine,” said Bmore POWER Supervisor Darryl Burrell, who speaks with people struggling with substance abuse often. “Most of the time if it’s a cocaine overdose or something related, it’s usually affiliated with heroin or fentanyl.”
There is no doubt, according to Dr. Michael Fingerhood, director of the division of addiction medicine at Johns Hopkins, “that the cocaine supply is very tainted” with fentanyl in Baltimore. Fingerhood said the combination can be dangerous.
People seeking cocaine may not use opioids, he said, and may not have built up a tolerance to them. For people who have no tolerance to opioids, he said, “any amount of fentanyl is likely to cause an overdose death.”
Fingerhood said he recently saw a patient who thought she was just using cocaine, and nearly died due to an overdose. Her drug screen also found fentanyl.
She was angry, Fingerhood recalled. “Why would someone sell me cocaine that was tainted with fentanyl when I wanted to buy just cocaine?” she asked.
He’s also worried about patients who are in treatment for an opioid use disorder and doing well on buprenorphine, a replacement treatment. A few may continue to use some cocaine intermittently and risk using fentanyl, too.
McDonald said that recently, there’s been something different about the cocaine he’s getting.
He trusts his dealers, he said, but he can tell the cocaine is tainted with something. It tastes more “chemical-y,” he said, and the high feels different too. “It feels like an anxiety attack, and is way more intense,” he said. “There’s more anxiety involved now.”
People who think they are buying heroin or fentanyl, may instead get a substance with cocaine or other drugs added to it, according to Dr. Zachary Dezman, an associate professor in the departments of emergency medicine and epidemiology and public health at the University of Maryland School of Medicine and a practicing emergency physician at UMD Medical Center Midtown Campus.
Some of Dezman’s patients tell him they prefer a heroin high to a fentanyl high. “They say it’s like falling down a black hole, whereas heroin will be a very relaxing sleep,” he said.
One motivation for dealers to add cocaine or other substances into fentanyl, Dezman said, may be to modify or improve the experience of using the drug. But fentanyl is also cheaper for suppliers to produce and more potent, according to federal officials, which is why dealers may add it to other drugs.
The rise in deliberate co-use shouldn’t be surprising, said Dr. Daniel Ciccarone, professor of family and community medicine at University of California, San Francisco, due in part to what he calls “the fourth wave” of the opioid overdose crisis.
U.S. opioid overdose deaths have come in three waves: The first, which began rising around 1999, were deaths due to prescription opioids, according to a paper authored by Ciccarone. The second, which began increasing significantly after 2010, were heroin-related deaths. And the third, which began rising significantly around 2014, were synthetic opioid-related deaths, which are mostly “illicit fentanyl and fentanyl analogs,” it said.
The U.S. has since entered a fourth wave: deaths due to cocaine and methamphetamine used in combination with opioids, Ciccarone said.
What’s happening, he said, is that people’s bodies may be getting tolerant of fentanyl, and they are seeking to “boost” it. One way to do that is just to use more of the drug, “and people are definitely doing that,” Ciccarone said. The other way is to add cocaine, or, more popular on the West Coast, methamphetamine, he said.
Ciccarone and other experts said opioids and cocaine have been a widely liked combination for a long time, known as a “speedball.”
Adding opioids can mellow out a cocaine high, Burrell said. It may also help elongate a fentanyl high, which does not last very long.
McDonald said he combines cocaine and fentanyl because “they complement each other.”
The high from fentanyl, he said, “is definitely a good feeling,” but it only lasts for a short time. Adding cocaine to the mixture draws the high out a little longer, he said.
For a long time, Burrell said, people combined heroin and cocaine. But heroin is now harder to find in Baltimore. The supply of fentanyl has grown.
That combination is something the Bmore POWER team is concerned about, Burrell said, because it becomes dangerous when people think they can use fentanyl like they usedheroin, in large amounts at once.
“If you did the same thing that you did with heroin, the outcome is not going to be the same. You can die from that,” he said.
The team emphasizes to anyone struggling with substance abuse, especially those using fentanyl, to “go slow,” a slogan that is part of a campaign Bmore POWER created with support from Behavioral Health System Baltimore, the Johns Hopkins Center for Communication Programs and Mission Media.
“Take your time with it,” Burrell said. For example, instead of sniffing a whole pill of fentanyl, he said, sniff half and see how you feel before using the rest.
On a recent November morning, Burrell pointed to several pouches of Narcan and fentanyl strips resting on the table — ready to be handed out to passersby as part of “harm reduction and risk reduction” efforts to prevent overdoses and help community members. Harm reduction groups emphasize a non-judgmental approach and direct outreach to people who use drugs.
And, Burrell said, if someone tells him they want help, “We will use every available resource to make sure you get the help you need.”
In a couple of hours, the table, set up by Bmore POWER, an outreach team part of Behavioral Health System Baltimore, on a corner in East Baltimore, was almost empty. The team goes out seven days a week to different locations across Baltimore City , Burrell said.
Most of Bmore POWER’s members have lived experiences with selling or using drugs. Burrell said that allows them to better connect with people in the communities they serve.
McDonald, who experiences homelessness, said it’s hard to stop using drugs, and until he can, safety measures like Narcan feel necessary. Though he uses fentanyl, it still scares him.
“The fear is always there,” McDonald said.