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Global cocaine production hit an all-time high, followed by record cocaine seizures, consequences, and deaths

Cocaine accounts for nearly one-third of U.S. overdose deaths.

Cocaine enforcement has intensified, targeting maritime routes and cartel leadership to reduce access and use.

With cocaine, the overdose bedside reflects decisions made thousands of miles away. Cocaine is clearly a major threat worldwide.

A decade ago, it would have seemed highly implausible that cocaine would account for nearly one-third (28%) of U.S. overdose deaths. Yet by 2023, approximately 30,000 overdose deaths in the U.S. involved cocaine. Synthetic opioids, particularly fentanyl, remain the principal driver of death, followed by cocaine.

Acute cocaine toxicity may cause arrhythmia, seizure, ischemic and hemorrhagic stroke, and sudden cardiac death. Chronic use contributes to cardiomyopathy, accelerated atherosclerosis, neurocognitive impairment, mood disorders, and psychosis. The drug’s effects generate immediate and cumulative cardiovascular risks.

The question is not just why an excessive flow of cocaine is happening, but how we react to this threat.

To understand the cocaine resurgence, let’s start with Colombia, where coca is grown. I have visited indigenous people and coca farmers, most recently in 2021 (see picture). Roughly up to 92% of cocaine seized on the streets of the U.S. originates in Colombia.

Beginning in 2016 and especially accelerating between 2020 and 2023, record amounts of coca were cultivated and record amounts of cocaine were produced, as documented by the United Nations Office on Drugs and Crime. By 2022, the estimated potential production in Colombia had more than tripled from 2015.

Improved, more resilient coca plant varieties, combined with better techniques, led to exploding production, with potential yields increasing by more than 50% in the last reported period. Colombia produced an estimated 3,000 metric tons of cocaine in 2024. In fiscal 2025, the U.S. Coast Guard reported a record-setting seizure of nearly 510,000 pounds of cocaine in the eastern Pacific and Caribbean.

Expanded cocaine production in Colombia has translated into greater availability in North America and Europe and more deaths. The Drug Abuse Warning Network (DAWN) estimates that roughly 354,000 cocaine-related emergency department visits occurred in the U.S. in 2023 and 393,000 in 2024. As with most items,greater supply brought lower prices—and lowered barriers to first use. Cocaine’s addictive pharmacology itself sustains repeated use. Stimulant co-involvement is present in most fentanyl-related overdoses.

As drug historian David T. Courtwright told me at the University of North Florida recently, “the late twentieth-century cocaine boom pushed up cocaine consumption in North America. The European market is now huge. Use is growing in East Asia and Australia. Cocaine smuggling is an international enterprise, with transshipment points in Africa and the Middle East.

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"The history of important psychoactive drugs is mostly a history of regionally traded goods like coffee and wine that became, with enterprise, bihemispheric commodities. Cocaine did it twice, first as a novel licit drug in the late nineteenth and early twentieth centuries and then as a popular illicit drug in the late twentieth and early twenty-first centuries.”

Cocaine, and methamphetamine, can be lethal when either is taken alone. But the modern speedball, a combination of fentanyl with cocaine or methamphetamine, significantly amps up medical risks. Stimulants can mask sedation and delay recognition of respiratory depression, increasing fatal overdose risk. Patients may present with mixed sympathomimetic and opioid features, complicating rapid assessment and management.

Cocaine is today a hot global commodity. The Colombian cocaine market is in a massive boom, with the industry generating an estimated $15.3 billion in annual revenue, roughly 4.2% of the country's GDP.

While the U.S. is the primary destination, there are recent shifts. The European cocaine market has expanded dramatically. Use is increasing in East Asia and Australia. Smuggling routes now traverse Africa and the Middle East.

The Expanding Stimulant Market: Methamphetamine

In Mexico, after 2014–2015, methamphetamine production increased sharply, with falling prices and rising purity. Methamphetamine use dominates many Western states; cocaine retains strength from Miami throughout the East.

Consequently, a new trend in the U.S. is taking multiple stimulants. Toxicology data have been demonstrating increasing use of cocaine and methamphetamine together. Overdose risk is increasingly driven by fentanyl co-use, by smoking or injection, or inadvertent co-use due to fentanyl contamination.

'Pink Cocaine" and Other Combinations

A further complication of the stimulant drug problem is so-called “pink cocaine” (often called 2C, tusi, tucibi, or tuci). Pink cocaine is frequently marketed as cocaine or a premium "new" drug as a way to increase sales and cater to, or deceive, users in the club and rave scene. It typically contains little or no cocaine but is comprised of mixtures of ketamine, MDMA, methamphetamine, caffeine, novel psychoactive substances, and occasionally, fentanyl, dyed pink for branding.

There is no uniformity across batches, leading to increased toxicologic unpredictability. Emergency presentations of pink cocaine may involve dissociation; sympathomimetic toxicity (severe tachycardia, hypertension, profuse sweating); serotonergic excess or opioid effects, depending on the types and numbers of adulterants.

Unlike consuming a slice of bread, a new user has to experience cocaine to understand its quality, intensity, and effects. As a result, initial demand may be low, but low-cost access and a sampling build the cocaine user base.

Illicit drug markets obey the same economic principles as legal markets. When supply expands substantially at the source, prices fall (or purity increases at a stable price), barriers to experimentation decline, and downstream morbidity and mortality rise.

In addition to innovations in Colombian cocaine cultivation, the current market differs from prior cocaine waves because it exploits the U.S.'s polysubstance user market and delivery infrastructure. Cocaine distribution currently piggybacks on fentanyl and methamphetamine trafficking networks, creating vertically integrated supply chains managed by sophisticated transnational drug organizations. From an economic standpoint, the cocaine production expansion has translated into greater cross-selling of a variety of speedballing substances to consumer markets in the U.S., Europe, and globally.

Enforcement has intensified with the re-emergence of Colombia's cocaine production and processing, including attacks on maritime trafficking routes and high-value cartel targets. The recent designation by the U.S. of major cartels as terrorist organizations represents a conceptual shift from a law-enforcement–centered “war on drugs” toward a more literal war framework.

Such designation expands authority and coordination. But if history is any guide, targeted offensives only temporarily disrupt logistics, while illicit markets adapt. Short-term supply shocks may reduce access and increase prices and use, leading to changes in purity, adulteration, and substitution—paradoxically elevating overdose risk.

Major offensives such as capturing or killing cartel leaders temporarily disrupt supply chains, but they rarely produce sustained scarcity or durable price increases. Trafficking networks adapt. New leaders emerge. Routes shift. New actors enter profitable markets.

Consequently, for supply-reduction-related enforcement efforts to reduce harm, they must continuously adapt, focusing on increasing the cost of cocaine, decreasing cocaine use and deaths, and interrupting the drug supply in new and varied ways. As long as consumer demand remains strong and cocaine profit margins remain high, supply chains and drug smugglers remain tough, resilient, and innovative.

Cocaine is back—not because its pharmacology changed but because its market did. As we learned in the 1980s during the last cocaine epidemic, cocaine epidemics do not end in isolation; they are shaped by lived experiences, public perception, enforcement intensity, price, competing substances, treatment accessibility, early intervention, and prevention.

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