Stimulant overdoses surge as fentanyl deaths finally fall, and naloxone can't fix it

Stimulant overdoses are climbing across much of the US, according to recently released provisional data from the Centers for Disease Control and Prevention. While fentanyl-involved deaths fell to pre-pandemic levels nationally for the first time in 2025, cocaine deaths rose in 13 states and methamphetamine deaths rose in eight. Arizona is one of the places where non-fatal stimulant overdoses are hitting record highs.

Dr Taylor Nichols, an emergency and addiction medicine physician in Sacramento, said stimulants "filled the gap" left as fentanyl deaths declined. She also warned that California's overdose decline "was not nearly what we expected." Methamphetamine and cocaine are the most common illicit stimulants driving the trend.

The problem is that the playbook that saved lives during the opioid crisis doesn't transfer cleanly. Public health campaigns taught people to spot slowed or stopped breathing and hit it with naloxone, but a stimulant overdose looks nothing like that. "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 the SafeSpot Overdose Hotline, a Boston Medical Center-run service for people using drugs alone.

Extreme overstimulation strains the heart and brain, producing heart attacks, strokes, seizures, chest pain and shortness of breath — all reasons to call 911 immediately. Nichols and Murray both push the Be Fast stroke mnemonic (Balance, Eyesight, Face droop, Arm weakness, Speech, Time to call 911). If someone loses consciousness, opioids may be involved too, and naloxone is still safe to use.

Heat makes it worse. Nichols said high doses in hot climates can trigger hyperthermia, which can cause significant brain damage or death. Murray added that staying hydrated helps prevent overheating, and Dalton Barrett, a paramedic managing opioid settlement funds in rural Edgecombe county, North Carolina, advises cutting external stimulation — music, bright lights, crowds — while waiting for an ambulance so patients don't turn aggressive and end up restrained or tased.

Prolonged sleepless binges can also bring on psychosis and paranoia. Murray, who has a history of meth and stimulant use, said telling someone their delusion isn't happening doesn't make it feel less real — validating that the experience is frightening works better. He noted most fatal stimulant overdoses involve other substances, but older men with heart problems are most at risk of dying from stimulants alone, and said criminalization and abstinence-only messaging make it hard to study how to keep people healthier.