Fentanyl-stimulant overdose deaths surge among older adults

Overdose deaths in adults age 65 and older from fentanyl mixed with stimulants, such as cocaine and methamphetamines, have surged 9,000% in the past eight years, matching rates found among younger adults, according to research presented at the ANESTHESIOLOGY^® 2025 annual meeting.

The study is among the first to use Centers for Disease Control and Prevention (CDC) data to show that older adults, a group often overlooked in overdose research, are part of the broader rise in fentanyl-stimulant overdose deaths. Adults 65 years and older are especially vulnerable to overdoses because many live with chronic health conditions, take several medications and process drugs more slowly due to age. 

The opioid epidemic has unfolded in four waves, each characterized by a different type of opioid driving the increase in overdose deaths: prescription opioids in the 1990s; heroin starting in 2010; fentanyl starting in 2013; and a mix of fentanyl and stimulants starting in 2015.

A common misconception is that opioid overdoses primarily affect younger people. Our analysis shows that older adults are also impacted by fentanyl-related deaths and that stimulant involvement has become much more common in this group. This suggests older adults are affected by the current fourth wave of the opioid crisis, following similar patterns seen in younger populations."

Gab Pasia, M.A., lead author of the study and medical student at the University of Nevada, Reno School of Medicine

Researchers analyzed 404,964 death certificates that listed fentanyl as a cause of death from 1999 to 2023, obtained from the CDC Wide-ranging Online Data for Epidemiologic Research (WONDER) system. Older adults (age 65+) represented 17,040 and younger adults (ages 25–64) represented 387,924 of the death certificates.

Overall, fentanyl-related deaths between 2015 and 2023 increased from 264 to 4,144 in older adults (1,470% increase) and 8,513 to 64,694 in younger adults (660% increase). The analysis revealed a growing number of fentanyl-stimulant related deaths, particularly among adults age 65 or older. Among this group, fentanyl-stimulant deaths rose from 8.7% (23 of 264 fentanyl deaths) in 2015 to 49.9% (2,070 of 4,144 fentanyl deaths) in 2023, a 9,000% increase. For younger adults, fentanyl-stimulant deaths increased from 21.3% (1,812 of 8,513 fentanyl deaths) in 2015 to 59.3% (38,333 of 64,694 fentanyl deaths) in 2023, a 2,115% increase.

The researchers highlighted data from these individual years because 2015 marked the onset of the fourth wave of the opioid epidemic and was also the year fentanyl-stimulant deaths among older adults were at their lowest, and 2023 as it was the most recent year of CDC data available.

The researchers noted that the rise in fentanyl deaths involving stimulants in older adults began to sharply rise in 2020, while deaths linked to other substances stayed the same or declined. Cocaine and methamphetamines were the most common stimulants paired with fentanyl among the older adults studied, surpassing alcohol, heroin and benzodiazepines such as Xanax and Valium.

"National data have shown rising fentanyl-stimulant use among all adults," said Mr. Pasia. "Because our analysis was a national, cross-sectional study, we were only able to describe patterns over time - not determine the underlying reasons why they are occurring. However, the findings underscore that fentanyl overdoses in older adults are often multi-substance deaths - not due to fentanyl alone - and the importance of sharing drug misuse prevention strategies to older patients."

The authors noted anesthesiologists and other pain medicine specialists should:

• Recognize that polysubstance use can occur in all age groups, not only in young adults.
• Be cautious when prescribing opioids to adults 65 or older by carefully assessing medication history, closely monitoring patients prescribed opioids who may have a history of stimulant use for potential side effects, and considering non-opioid options when possible.
• Use harm-reduction approaches such as involving caregivers in naloxone education, simplifying medication routines, using clear labeling and safe storage instructions and making sure instructions are easy to understand for those with memory or vision challenges.
• Screen older patients for a broad range of substance exposures, beyond prescribed opioids, to better anticipate complications and adjust perioperative planning.

"Older adults who are prescribed opioids, or their caregivers, should ask their clinicians about overdose prevention strategies, such as having naloxone available and knowing the signs of an overdose," said Richard Wang, M.D., an anesthesiology resident at Rush University Medical Center, Chicago and co-author of the study. "With these trends in mind, it is more important than ever to minimize opioid use in this vulnerable group and use other pain control methods when appropriate. Proper patient education and regularly reviewing medication lists could help to flatten this terrible trend."