Stimulant overdoses rise as opioid deaths fall, but recognizing them is more complex

Overdoses involving stimulants are climbing in many parts of the United States, according to recently released data from the Centers for Disease Control and Prevention, even as deaths from opioids decline. Experts warn that recognizing and responding to a stimulant overdose is far more complex than dealing with an opioid overdose.

Provisional CDC fatality data shows that while fentanyl-involved overdose deaths dropped to pre-pandemic levels nationally for the first time in 2025, deaths involving cocaine rose in 13 states and deaths involving methamphetamine increased in eight. In some states, including Arizona, non-fatal stimulant overdoses are reaching record highs.

"The rate of overdose decline was not nearly what we expected" in California, said Dr Taylor Nichols, an emergency and addiction medicine physician based in Sacramento. Nichols said stimulants "filled the gap" left by declining fentanyl overdoses. Methamphetamine and cocaine are the most common illicit stimulants.

Public health messaging has taught many people to recognize opioid overdoses and respond with naloxone, but education about stimulant overdoses has been less clear-cut. "As a bystander, it is a lot more challenging to decide whether something is a stimulant overdose when you compare to how clear-cut a true opioid overdose is," said Stephen Murray, director of SafeSpot Overdose Hotline, a safety service for people using drugs alone that is run out of a Boston medical center.

Murray, a former paramedic who runs overdose response trainings for paramedics across the country, said slowed or stopped breathing is a clear sign of an opioid overdose, while stimulant overdoses vary widely. "A stimulant overdose can be as simple as releasing too much stimulation into your brain and into your body," Nichols said. Extreme overstimulation strains the heart and brain, which can lead to heart attacks and strokes.

Nichols and Murray recommend learning stroke warning signs through the Be Fast mnemonic: balance loss, eyesight changes, face droop, arm or leg weakness, speech difficulty, and time to call 911. Stimulant-induced shortness of breath, seizures and chest pain also require immediate medical attention. Calling 911 is advised for any overdose, but while bystanders can save lives with naloxone, no equivalent tool exists for a stimulant-induced heart attack, stroke or seizure. If someone loses consciousness during a stimulant overdose, opioids may also be involved, and naloxone is safe to use.

High doses of stimulants are especially dangerous in hot climates. "You can develop hyperthermia, where your body gets too hot, and that can end up resulting in significant brain damage or death," Nichols explained. People using stimulants sometimes forget to eat or drink, and Murray said a conscious effort to stay hydrated can prevent overheating.

Dalton Barrett, a paramedic and manager of opioid settlement funds in rural Edgecombe County, North Carolina, recommends keeping stimulant overdose patients as calm as possible while waiting for an ambulance by removing external stimulation such as music, bright lights and crowds. "What we don't want to happen is we get over there, and now they're aggressive with the EMS staff, and now law enforcement's coming, and the person gets tased or maced or put in handcuffs," Barrett said, noting that such altercations distress patients and make them harder to treat.

Prolonged, sleepless stimulant binges can also lead to psychosis and paranoia. "I have a history of meth and stimulant use, and have been in quasi-meth psychosis before," Murray said. "Telling someone that [their delusion] is not happening doesn't make it feel less real." He suggests validating that the experience is scary, and making sure the person will not be perceived as threatening when responders arrive, which can include calmly clearing away anything that might appear incriminating, like a weapon. Ideally, he said, emergency medical services and law enforcement coordinate to keep patients safe, and anyone who is forcibly restrained should also receive medical sedatives.

Most fatal stimulant overdoses also involve other substances, but Murray noted that older men with heart health problems are most at risk of dying from stimulants alone. "The people who die have the American diet and lack of exercise sort of stuff going on. Then when you mix in high-potency stimulants, especially if people are injecting them, that is a deadly combination," he said. He added that he wishes people could speak openly with their doctors about drug use, because improving heart health can help prevent stimulant overdoses even when someone continues to use, but criminalization and abstinence-only messaging make that difficult.