Why Are So Many People Mixing Opioids and Stimulants?

Man is looking at the mirror

The use of an opioid along with a stimulant drug is a growing trend among people who use drugs, especially among those who inject drugs. This practice has, for several decades, been called speedballing. Speedballing originally referred to injecting heroin and cocaine at the same time, possibly in the same needle. Now, there are many types of opioids and stimulants that may be mixed.

This practice comes with its own set of dangerous physical and mental effects that should be known by any person who has a loved one or friends who are mixing these drugs. Helping someone avoid the risks of these mixed drugs starts with understanding why people do it and what harm can result.

What’s the Reasoning Behind This Mixture?

Very sick woman

Primarily, the user hopes to ease the negative effects of one of the drugs. If they were using opioids, they want to avoid the drowsiness or dope-off of drugs like heroin, fentanyl, oxycodone or other opioids. If they were using a stimulant like cocaine, they might add an opioid in an attempt to avoid the anxiety, agitation and paranoia that can result.

It is possible that an increased supply of inexpensive methamphetamine may be contributing to this trend. A drug user also may feel they can achieve a synergistic high by mixing these drugs, and therefore maintain a greater “normalcy” by avoiding either too much agitation or too much dopiness.

A drug user may also be seeking the high that occurs from the simultaneous use of these two types of drugs, which can feel like a rush of energy, relaxation and euphoria all at once.

Which Drugs Are Being Mixed?

There’s a very long list of opioid drugs, both prescription and illicit, that may be used in one of these mixtures.


  • Heroin
  • Buprenorphine
  • Codeine
  • Dihydrocodeine
  • Hydrocodone
  • Hydromorphone
  • Levorphanol
  • Loperamide
  • Meperidine
  • Methadone
  • Morphine
  • Oxycodone
  • Oxymorphone
  • Pentazocine
  • Propoxyphene
  • Tapentadol
  • Tramadol
  • Prescription fentanyl
  • Illicitly manufactured fentanyl
  • Any illicit fentanyl analog like alfentanil, sufentanil or carfentanil
  • Other new illicit opioid drugs such as U-4770, isotonitazene, brorphine, metonitazene and others.


  • Cocaine
  • Adderall
  • Ritalin
  • Concerta
  • Methamphetamine
  • Amphetamine
  • Dexedrine
  • Dextroamphetamine
  • Cathinones
  • Methylphenidate
  • Atomoxetine
  • Modafinil
  • Armodafinil

Speedballing: The Original Opioid-Stimulant Mix

As mentioned, speedballing has long been the preferred term for the combination of an opioid and stimulant. Speedballs were originally injected at the same time, using the same needle, but the drugs could also be snorted.

In 2019, the DEA identified another combination they called “super speedballs,” consisting of cocaine, heroin and fentanyl.

Adding heroin to cocaine eases the sharp comedown from short-acting cocaine, while cocaine helps prevent the lethargy that occurs after using heroin.

But these two drugs have at times been a deadly combination. Actor and comedian John Belushi died of a toxic dose of heroin and cocaine in 1982. In 1993, another actor, River Phoenix, also died of a combination of heroin and cocaine. After his death, Phoenix’s body showed no signs of injections.

Fentanyl in Meth or Cocaine Can Quickly Cause Addiction or Death

Drug dealer mixing cocaine with fentanyl

Speedballing may actually be unintentional, such as when fentanyl is added to cocaine or methamphetamine supplies by a drug dealer. The person who thinks they are using cocaine could actually be getting both cocaine and fentanyl at once because their drug dealer mixed fentanyl into the powdered cocaine or meth they were selling.

As fentanyl is far more addictive than cocaine, a drug dealer may feel like he is keeping his customers dependent on him by slipping them fentanyl. If the customers quickly become addicted to the mix, they will need to seek him out for more supplies.

But in doing so, the drug dealer can also kill his customers. In 2018, 18 drug users in Philadelphia fatally overdosed after smoking crack cocaine that was mixed with fentanyl. Similar problems have shown up in New York City and British Columbia.

It’s important to note that a person who routinely consumes a stimulant may not have any tolerance for an unexpected dose of an opioid. Even a very small amount of fentanyl in their stimulant could cause their death.

Which Drug Combinations Cause the Most Deaths?

According to the Centers for Disease Control and Prevention, opioids mixed with stimulants were involved with a significant portion of drug overdose deaths in 2020.

  • Illicitly manufactured fentanyl or an analog plus cocaine = 13% of overdose deaths
  • Illicitly manufactured fentanyl or an analog plus methamphetamine = 7%
  • Illicitly manufactured fentanyl or an analog, heroin and cocaine = 3%
  • Methamphetamine and an opioid or stimulants = 2%

Health Effects of Mixing Stimulants with Opioids


This combination of drugs can result in any of the negative side effects associated with the use of either an opioid or a stimulant. Therefore, any of the following effects are possible.

  • Confusion
  • Lack of coherence
  • Stupor
  • Dopiness
  • Paranoia
  • Lack of sleep causing poor focus
  • Uncoordinated motor skills

The following serious health effects are also possible:

  • Psychosis
  • Stroke
  • Aneurysm
  • Respiratory failure

Some users may feel that by adding a stimulant to a depressant (opioid), they can avoid the possibility that the depressant will stop their breathing, causing their death. As too many have found out, this isn’t always true.

If the combination contains cocaine and an opioid, the effects of the cocaine will wear off much faster than the effects of the opioid. In this case, then, the person’s breathing could be speeded up by the cocaine but then drop to life-threatening slowness as soon as the cocaine wears off.

If a person’s combination contains methamphetamine and heroin, the effects of methamphetamine will last much longer than the effects of heroin. The methamphetamine could speed up their heart rate while the heroin tries to slow it down. If this conflict causes their heart rate to change very quickly, the sudden change can trigger arrhythmias, heart failure or stroke.

In addition to all these other serious effects, cocaine and heroin together can cause severe cognitive, physical and psychological effects after long-term use.

Another complicating factor in the use of both types of drugs is the difficulty medical staff have in helping a person who’s experiencing a medical emergency. The mixture of drugs can make it very difficult to tell what is causing the person’s physical problem.

The Addictiveness of These Drugs

Family Intervention

While cocaine is definitely addictive, methamphetamine and fentanyl are even more highly addictive. In some people, just one use is all it will take to trap them in addiction.

No young person has a goal to be addicted when they are grown up. Family members who try to help an addicted person and meet with resistance may conclude that the person wants to be an addict. This is never the truth. No one wants to be an addict. No one wants to be caught in this trap.

A young person must be taught that these drugs can trap them, possibly after one use. There is also a distinct chance of fatal results or permanent damage from the use of these combinations.

Someone who has become addicted needs an effective drug rehab program. Most people need longer than 28 days to recover from addiction. Getting the drugs out of their bodies, learning new life skills and developing a healthier pattern of living takes most people longer than the one month adopted by many drug rehab programs.

It is possible to help a person who has become addicted to speedballs or one of these other combinations. It takes determination and dedication to support their recovery and find them the best drug rehab possible.


  • “2019 Drug Threat Assessment.” DEA, 2019. DEA
  • “Stimulant Guide.” CDC, 2023. CDC
  • “Drug Overdose Deaths in 28 States and the District of Columbia.” CDC, 2022. CDC


Karen Hadley

For more than a decade, Karen has been researching and writing about drug trafficking, drug abuse, addiction and recovery. She has also studied and written about policy issues related to drug treatment.