More than 100,000 people in the United States died of unintentional poisoning in 2023. Illicit stimulants like cocaine and methamphetamine were involved in a significant number of those deaths.
Unlike stimulants, hallucinogens are rarely lethal on their own, but can cause bizarre and violent behavior resulting in death. A working knowledge of stimulants and hallucinogens is therefore important in death investigation.
I’ve described the general principles and challenges of drug death investigation and specifics of opioid drug death investigations in earlier posts. This post covers key behavioral and physiological effects of stimulants and hallucinogens relevant to those who investigate and certify drug deaths and those who write about them.
Profiles of Major Illicit Stimulants and Hallucinogens
Cocaine in Death Investigation
Cocaine, a potent stimulant, has been making a big comeback in recent years, especially in the Chicago area. Often it’s part of a “drug cocktail.” The combination of cocaine and heroin—known as a speedball—has been around for a long time. Now fentanyl is replacing heroin, making the new combo more deadly than the old one.
The Drug Enforcement Administration (DEA) found that 25% of cocaine samples tested in 2025 contained the synthetic opioid fentanyl. The more potent fentanyl is often what kills unsuspecting cocaine users, especially in the Northeastern United States. Fentanyl test strips might help, but few stimulant users have them on hand.
As chronic cocaine users age, they become more susceptible to the dangerous effects the drug can have on the heart and brain. But even younger people are vulnerable to cocaine’s lethal cardiovascular effects such as “heart attacks,” arrhythmias, or strokes. Emergency room urine drug screening can detect stimulants like cocaine (or its metabolite benzoylecgonine), but those tests are insensitive and unreliable. Because of the prevalence of drug use, coroners and medical examiners should order full toxicological testing in all sudden death cases.
There’s one more danger to be aware of with cocaine. When combined with alcohol (ethanol), the liver produces a compound called cocaethylene. Cocaethylene is also psychoactive, lasts longer than cocaine, and is more cardiotoxic than cocaine alone.
Methamphetamine and Amphetamines
The National Institute on Drug Abuse reported that from 2015 to 2019 overdose deaths involving stimulants other than cocaine (largely methamphetamine) surged from 5,526 to 15, 489. At the same time, the opioid epidemic, primarily fueled by fentanyl use, was peaking.
By 2021, almost one-third of drug overdose deaths in the United States involved the combination of a stimulant and fentanyl. In western states and in most states in the South and Midwest, that stimulant was usually methamphetamine, a synthetic substance. DEA seizures at illicit meth labs, as shown in the image, often yield large amounts of the substance.
Meth can render users hyperactive, paranoid, obsessive, and excessively anxious. Life-threatening physiologic effects include rapid heart rate, overheating, excessive sweating, hypertension, and seizures.
Methamphetamine and Heat Deaths
The rise in body temperature that can occur with methamphetamine has complicated death certification associated with excessive environmental heat. According to an Associated Press story, meth is the drug most often found in heat-related deaths in places like Maricopa County (Phoenix), Arizona. Did someone found on the street during a heat wave die of the methamphetamine they’d been using or of heat exposure? That’s become a controversial questions in places like south Texas and the Phoenix, Arizona area.
It can be challenging to sort out the primary cause of death when heat and drugs are involved, but it would be presumptuous to simply omit either factor on a death certificate. The effects of meth and heat can be additive or synergistic in causing death and it’s rarely possible to be certain which was the primary cause of death. Certainly both are problems that need to be addressed to reduce mortality.
A Case Study
Blood from multiple stab and slash wounds covered Freddy Lopez’s (not his real name) dead body. The deputy coroner took photos of the body and the knife on the floor beside him as the detective spoke with the family. “We heard loud noises up there, like a fight,” said Freddy’s brother. “Then it got quiet.” No one could remember anyone coming to the house and going up to Freddy’s room. A violent altercation, followed by a stabbing, everyone thought. But there was no sign of a killer.
A month later Freddy Lopez’s toxicology test came back positive for high levels of the hallucinogen phencyclidine (PCP, Angel Dust), along with alcohol and low levels of a prescribed antidepressant. Freddy’s death was ruled a suicide. NAME guidance states that “self-inflicted deaths committed while under the influence of a mind-altering drug may be classified as suicide.”
Phencyclidine (PCP)
Phencyclidine is notorious for causing severe dysphoria and hallucinations. Bizarre behavior, including extreme self-harm leading to death as in the case of Freddy Lopez, is a known effect of the drug.
Ketamine
The December 2023 death of Matthew Perry from the “acute effects of ketamine” raised awareness of ketamine’s dangers. The CDC reported that from July 2019 to June 2023 ketamine, a legal anesthetic also used for treatment-resistant depression, was found in less than 1% of overdose deaths. The percentage of overdose deaths involving ketamine, however, increased over those four years.
Ketamine can cause death in more ways than one. Physiologic effects like respiratory depression, arrhythmias, myocardial infarction, and seizures can be lethal. At high doses, mental disturbances like hallucinations—sometime referred to as being in a “k-hole”—can cause life-threatening behavior.
Challenges in Stimulant and Hallucinogen Death Investigation
The increase in multisubstance use has made cause of death determination more complex for coroners and medical examiners. As a result, terms like “combined drug intoxication” are showing up on more death certificates.
Best practice calls for coroners and medical examiners to list all drugs that may have contributed to the death on the death certificate.
New Drug Identification
Identifying emerging drugs is critical to public health efforts and accurate death certification. The Novel Psychoactive Substances (NPS) Discovery program at the Center for Forensic Science, Research, and Education (CFSRE) has been on the forefront of this effort. Recently the Department of Justice “paused” federal funding for the NPS program, raising concern about whether it can continue.
Conclusions about Stimulants and Hallucinogens in Death Investigation
Drugs like methamphetamine, cocaine, phencyclidine, and ketamine are common causes or contributors to overdose/intoxication deaths.
Coroners and medical examiners should be aware of the psychoactive and physiologic effects of stimulants and hallucinogens when conducting death investigations.
The illicit drug scene is constantly evolving. Accurate and complete certification of deaths involving drugs is essential to tracking trends in substance use.