Stimulants Signals Alert | Millennium Health

Millennium Health Signals Alert®

Stimulant Use Soars, Effective Interventions Desperately Needed

Published January 2026

Urine drug testing (UDT) data show stimulant use climbing sharply, detected at nearly twice the rate of fentanyl in 2025

Although fentanyl’s contribution to the overdose crisis has dominated the national conversation for over a decade, overdoses involving stimulants—alone and in combination with fentanyl—have increased and are gaining more attention.^1,2
Because overdose data do not fully capture the scope of illicit stimulant use in the U.S., this analysis of over 1.6 million clinical UDT specimens collected from adults with a substance use disorder (SUD) provides insight into the broader picture of illicit stimulant and fentanyl use—each in total and in combination with one another—between January 2016 and November 2025.

National Comparison of Stimulant Use With and Without Fentanyl Relative to Total Fentanyl Detection

National, yearly urine drug testing (UDT) detection rates (with 95% confidence intervals, light shading) for total stimulants (red line; includes methamphetamine and/or cocaine), total fentanyl (gray line), stimulants with fentanyl (blue line), and stimulants without fentanyl (tan line) in patient specimens collected from January 1, 2016 through November 30, 2025. Detection rates were estimated using logistic regression.

Key Findings

The detection rate for stimulants (i.e., cocaine and/or methamphetamine; ■) has consistently been higher than that of fentanyl (■), with stimulants being detected at almost double the rate as fentanyl in 2025 (i.e., 26% vs. 14%, respectively) and still climbing.
Co-detection of fentanyl and stimulants (■) has increased over time and continued to rise in 2025; over 85% of those using fentanyl (■; 14%) also tested positive for a stimulant (■; 12%) in 2025.
Although the detection of stimulants without fentanyl (■) had generally decreased since 2016, it began to increase in 2024; stimulant use without fentanyl (■; 14%) is now detected at the same rate as fentanyl overall (■; 14%).

Annual detection rates were rounded to the nearest whole number. Note: Co-detection of stimulants and fentanyl via UDT does not differentiate between intentional use of and inadvertent exposure to either drug/drug class.

Key Takeaways

These findings reveal aspects of the drug use epidemic that are not fully captured by overdose data and highlight the underappreciated contribution of illicit stimulant use to the total burden of drug use among people who have a SUD.
The continued rise of stimulant use, both with and without fentanyl, suggests that cocaine and methamphetamine are readily available in the illicit drug supply and that demand for these drugs continues to grow—fueling the ongoing “fourth wave” of the overdose crisis and potentially setting the stage for a larger shift toward the use of illicit stimulants over opioids in the future.
Beyond fatal overdose, stimulant use is associated with many short- and long-term negative health effects (e.g., psychosis, cardiovascular disease, infectious disease)^2-7 and the rapidly increasing rates of stimulant use illustrated above are a clear indication that enhanced screening and evidence-based interventions (e.g., contingency management) for stimulant use disorder—as well as those specifically tailored to co-occurring opioid and stimulant use disorders—remain desperately needed.

Methods

Urine Drug Testing Data and Sample Population

This retrospective, cross-sectional analysis includes the evaluation of de-identified and aggregated definitive urine drug testing (UDT) results derived from testing with liquid chromatography-tandem mass spectrometry (LC-MS/MS) on patient urine specimens from across the U.S. and multiple health care specialties. The LC-MS/MS testing method is a laboratory-developed test with performance characteristics determined by Millennium Health, San Diego, California, which is certified by the Clinical Laboratory Improvement Amendments (CLIA) and accredited by the College of American Pathologists (CAP) for high-complexity testing.

1,693,201 UDT specimens representing nearly 531,891 unique patients were included in the analysis. Urine specimens were collected from patients aged 18 years or older between January 1, 2016, and November 30, 2025. Specimens were excluded from analysis if they were collected within 30 days of the previous specimen for any given patient. This filtering was performed to reduce the possibility that a given UDT result could reflect a previous instance of drug use that has already been captured by a previous UDT result. A 30-day interval was chosen because it represents a period that exceeds the expected window of detection for all drugs and metabolites in this study. In addition, specimens were selected based on the presence of a substance use disorder (SUD) diagnosis code provided by the ordering clinician. The International Classification of Diseases, Tenth Revision (ICD-10) SUD codes used in this study were: (1) F11 – Opioid related disorders, (2) F13 – Sedative, hypnotic, or anxiolytic related disorders, (3) F14 – Cocaine related disorders, (4) F15 – Other stimulant related disorders, (5) F16 – Hallucinogen related disorders, (6) F18 – Inhalant related disorders, and (7) F19 – Other psychoactive substance related disorders.

We studied UDT results consistent with illicit and/or non-prescribed use by excluding specimens with reported prescriptions for any of the drugs and drug categories below from analysis. The following drugs and drug categories were studied (specific analytes tested in parentheses): cocaine (benzoylecgonine), methamphetamine (methamphetamine), and fentanyl (fentanyl, norfentanyl). If any parent drug or metabolite within a drug category was ordered and detected in a specimen, the result for that drug or drug category was considered positive. All specimens evaluated in the current study had valid, clinician-ordered test results for fentanyl, cocaine and methamphetamine.

Statistical Methods

UDT detection rates (%) were modeled using logistic regression and adjusted detection rates (Least Square Mean marginal rates) and 95% confidence interval (CI) values (predicted probability) were calculated.

References

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Coffin PO, Suen LW. Methamphetamine Toxicities and Clinical Management. NEJM Evidence. 2023;2:12. doi:10.1056/EVIDra2300160
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Bach P, Ti L. Hepatitis C and Stimulant Use Disorder: Challenges and Opportunities. Clin Infect Dis. 2020;71(11):3009. doi:10.1093/cid/ciaa249