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Emerging Trends

Revised August 2015

New drugs and drug use trends often burst on the scene rapidly. NIDA’S Community Epidemiology Work Group (CEWG), which functioned through 2014, was a network of researchers in major metropolitan areas and some states across the United States that reported data on emerging trends and patters of drug use. NIDA’s National Drug Early Warning System (NDEWS) replaces the CEWG and reports on emerging trends and patterns of drug use in many of the same metropolitan areas and states as the CEWG, but also reports data from other areas of the nation, as problems arise. On this page we will provide periodic updates based on NDEWS reports and other reliable information, as well as links for where to go for more information.

The NDEWS Sentinel Community Site Reports for 2015 (describing drug use trends in the 12 NDEWS sentinel communities) are now avilable on the NDEWS website

Related News Release

Surge in Fentanyl Overdose Deaths

Updated July 9, 2015

A surge in overdose deaths related to fentanyl, an opioid 30 to 50 times more potent than heroin, has prompted Baltimore health officials to launch a public health campaign to raise awareness among drug users. Hundreds of people have overdosed on fentanyl across the nation since 2013, often as a result of using heroin that has been laced with the much stronger substance. A quarter of drug overdose deaths in Maryland now involve fentanyl, up from 4 percent in 2013. Opioid overdose can stop a person's respiration, and fentanyl can have this effect very quickly. Other parts of the country such as Detroit and surrounding suburbs are also seeing major surges in fentanyl use and fentanyl-related deaths. In some cases users are unknowingly taking fentanyl in what they believe to be pure heroin, but a growing number of opioid users are deliberately taking fentanyl.

Fentanyl and other opioid overdoses can be reversed if the drug naloxone (Narcan) is administered promptly. In a growing number of states, naloxone is being distributed to injection drug users and other laypersons to use in the event of overdose. For example, Baltimore's Staying Alive Drug Overdose Prevention and Response plan issues naloxone and training in its use.

Increasing Overdoses From Synthetic Cannabinoids (“Spice,” "K2,” etc.) in Several States

Updated May 8, 2015

Recent surges in hospitalizations and calls to poison control centers linked to consumption of synthetic cannabinoid products--sold under brand names like “Spice,” “K2,” "No More Mr. Nice Guy," and others--are being reported in several southern and northeastern U.S. states and have prompted officials to issue health warnings. After a surge in synthetic cannabinoid exposures and poison center calls in April and May, 2015, the Maryland Poison Center issued an urgent notice about the dangers of these drugsNew York Governor Andrew Cuomo issued an alert after more than 160 patients were hospitalized following synthetic cannabinoid use in under two weeks in mid April, 2015.

Synthetic cannabinoids are chemically related to THC, the active ingredient in marijuana, and are sometimes called “synthetic marijuana” or “legal marijuana,” but actually the effects can be considerably more powerful and more dangerous than marijuana. Users can experience anxiety and agitation, nausea and vomiting, high blood pressure, shaking and seizures, hallucinations and paranoia, and they may act violently.

The Maryland notice lists several chemical compounds in materials from crime labs, including MAB-/AB-CHMINACA, FUBINACA, FUB-PB-22, and XLR11. Besides the brand names above, the New York State health alert lists other common names: Blonde, Summit, Standard, Blaze, Red Dawn X, Citron, Green Giant, Smacked, Wicked X, AK-47; recent reports have involved products with the names Geeked Up, Ninja, Caution, Red Giant, and Keisha Kole.

For more information on synthetic cannabinoids, see DrugFacts: K2/Spice ("Synthetic Marijuana")

"Flakka" (alpha-PVP)

Updated April 6, 2015

Use of a dangerous synthetic cathinone drug called alpha-pyrrolidinopentiophenone (alpha-PVP), popularly known as "Flakka," is surging in Florida and is also being reported in other parts of the country, according to news reports.

image of bottle with white crystals pouring out

Alpha-PVP is chemically similar to other synthetic cathinone drugs popularly called "bath salts," and takes the form of a white or pink, foul-smelling crystal that can be eaten, snorted, injected, or vaporized in an e-cigarette or similar device. Vaporizing, which sends the drug very quickly into the bloodstream, may make it particularly easy to overdose. Like other drugs of this type, alpha-PVP can cause a condition called "excited delirium" that involves hyperstimulation, paranoia, and hallucinations that can lead to violent aggression and self-injury. The drug has been linked to deaths by suicide as well as heart attack. It can also dangerously raise body temperature and lead to kidney damage or kidney failure.

U.S. and British Columbia Issue Alerts on Fentanyl

Updated March 18, 2015

The U.S. Drug Enforcement Agency (DEA) has issued a nationwide alert about the dangers of fentanyl and related compounds (fentanyl analogues). Fentanyl, an opioid that is 50-100 times more powerful than morphine, is both abused on its own and commonly added to heroin to increase its potency. Fentanyl and fentanyl-laced heroin have been a concern for over a decade and have caused numerous overdose deaths among injection drug users in several U.S. cities.

Heroin is not the only drug that can be laced with fentanyl, however. Officials in Vancouver, British Columbia, Canada, recently issued public warnings about a wide range of fentanyl-laced drugs causing overdose deaths among users. They warn that fentanyl is now being concealed in non-injection drugs, including oxycodone and various "party drugs" in powder or pill form, as well as in marijuana (although no deaths have been confirmed from fentanyl-laced marijuana). Because of this new threat, British Columbia officials are urging all recreational drug users to "know their source."

HIV Outbreak in Indiana Linked to Abuse of Opana

Posted February 27, 2015

Health officials in Indiana have announced a fast-spreading outbreak of new HIV cases in the southeastern portion of the state that are linked to injection drug abuse of the powerful prescription opioid painkiller Opana. Injecting drugs and sharing injection equipment is one of the main routes of transmitting HIV. Also, a few new HIV cases in southeastern Indiana were transmitted sexually.

Officials advise that people in southeastern Indiana who have engaged in needle sharing or unprotected sex should get tested for HIV and then re-tested after 2-3 months, as HIV may not appear on tests immediately when the virus is contracted. To reduce risk of contracting HIV, avoid injection drug use, sharing or re-using needles, and having unprotected sex or sex with commercial sex workers.

Warning from Europe: "Superman" pills

Posted January 16, 2015

An alert was recently issued in The Netherlands warning about pills with a distinctive Superman logo, sold as MDMA (also called ecstasy or Molly) but actually containing a lethal dose of another substance, PMMA (paramethoxymethylamphetamine). These pills have not been reported in the U.S., but four people in the UK are thought to have died after taking these pills.

New Synthetic Cannabinoids—“Cloud 9,” “Mojo,” etc.

Posted November 13, 2014

Makers of designer drugs that are chemically similar to marijuana’s active ingredient THC—called synthetic cannabinoids or colloquially “synthetic marijuana” or “synthetic pot”—are constantly creating new products to evade legal bans on older compounds. Despite the similarity on the molecular level, these drugs are much more dangerous than marijuana, and have resulted in very serious health consequences including overdoses and aggressive or suicidal behavior in users.

Some new compounds have recently emerged that are sending many users to the hospital in cities around the country. They include:

  • AB-PINACA, AB-FUBINACA (sold as “Cloud 9,” “Relax,” or “Crown”) is sold as a liquid in eyedropper bottles and often used with vaporizing devices—e-cigarettes or “hookah pens.” Numerous hospitalizations in Michigan prompted the Macomb County Health Department to issue an emergency warning and ban on the sale of these drugs, which are reported to cause hallucinations, aggressive behavior, racing heartbeat, drowsiness, and vomiting.
  • MAB-CHMINACA, ADB-CHMINACA (sold as “Mojo,” “Spice,” “K2,” and “Scooby Snax”) resulted in over 150 hospital visits in Baton Rouge and Lafayette, LA in October, prompting the governor to ban the drug in that state. It is reported to cause severe agitation, anxiety, and paranoia; raised heartbeat and blood pressure; nausea and vomiting; muscle spasms, seizures, and tremors; intense hallucinations and psychotic episodes, including suicidal fixations and other harmful thoughts.

Read more about "K2" and "Spice" synthetic cannabinnoids

Caffeine Powder

Posted July 23, 2014

Caffeine powder

The death of an Ohio high school senior caused by an overdose of powdered caffeine has prompted the FDA to issue a safety advisory about caffeine powders. Bulk bags of pure caffeine powder are readily available online, and these products may be attractive to young people looking for added caffeine stimulation or for help losing weight, but they are extremely dangerous. Just a teaspoon of pure caffeine powder is equivalent to about 25 cups of coffee—a lethal amount. Besides death, severe caffeine overdose can cause fast and erratic heartbeat, seizures, vomiting, diarrhea, and disorientation—symptoms much more extreme than those of drinking too much coffee or tea or consuming too many sodas or energy drinks.

Although caffeine is generally safe at the dosages contained in popular beverages, caffeine powder is so potent that safe amounts cannot be measured with ordinary kitchen measuring tools, making it very easy to overdose on them even when users are aware of their potency. The FDA thus recommends that consumers avoid caffeine powder altogether, and wishes to alert parents to the existence of these products and their hazards.



Posted November 10, 2013

E-cigarettes are increasingly popular battery-operated devices marketed as a safer alternative to smoking conventional cigarettes. They produce flavored nicotine aerosol that looks and feels like tobacco smoke but without the tar or other chemicals produced by burning tobacco leaves. However, while e-cigarettes do not produce tobacco smoke, it is still unclear how safe they are. They still deliver nicotine, which is a highly addictive drug. Also, vapor from some e-cigarette products has been found to contain known carcinogens and toxic chemicals. Until more studies are conducted, there is no way of knowing what the health consequences of repeated exposure to these chemicals may be, whether e-cigarettes are any safer than conventional cigarettes, or if they are useful to help a person quit smoking.

For more information, see our Drug Facts: Electronic Cigarettes


Posted November 8, 2013

“Krokodil,” a toxic homemade opioid that has been used as a cheap heroin substitute in poor rural areas of Russia, has recently been featured in news reports alleging its appearance in parts of the United States. The CEWG is investigating, although the DEA has not yet confirmed any krokodil in this country.

Krokodil is a synthetic form of a heroin-like drug called desomorphine that is made by combining codeine tablets with various toxic chemicals including lighter fluid and industrial cleaners. Desomorphine has a similar effect to heroin in the brain, although it is more powerful and has a shorter duration. Krokodil gets its name from the scaly, gray-green dead skin that forms at the site of an injection. The flesh destroyed by krokodil becomes gangrenous, and, in some cases, limb amputation has been necessary to save a user’s life.

We will update this page with any further information on krokodil in the U.S., if cases are found.


Posted September 30, 2013

“N-bomb” refers to any of three closely related synthetic hallucinogens (25I-NBOMe, 25C-NBOMe, and 25B-NBOMe) that are being sold as legal substitutes for LSD or mescaline. Also called “legal acid,” “smiles,” or “25I,” they are generally found as powders, liquids, soaked into blotter paper (like LSD) or laced on something edible.

These chemicals act on serotonin receptors in the brain, like other hallucinogens, but they are considerably more powerful even than LSD. Extremely small amounts can cause seizures, heart attack or arrested breathing, and death. At least 19 young people are reported to have died after taking 25I- 25C- or 25B-NBOMe between March 2012 and August 2013.  People may ingest one of these drugs unknowingly, believing it to be LSD; a young man in one medical case report published in late 2014 experienced severe hallucinations and panic and attempted suicide after such an ingestion.

For more information, see http://www.deadiversion.usdoj.gov/drug_chem_info/nbome.pdf (PDF, 217KB)

“Syrup,” “Purple Drank,” “Sizzurp,” “Lean”

Posted May 26, 2013

Drinking prescription-strength cough syrup containing codeine and promethazine mixed with soda was referenced frequently in some popular music beginning in the late 90s and has now become increasingly popular among youth in several areas of the country, according to recent CEWG data. Codeine is an opioid that can produce relaxation and euphoria when consumed in sufficient quantities. Promethazine is an antihistamine that also acts as a sedative. Users may also flavor the mixture with the addition of hard candies.

Codeine and other opioids present a high risk of fatal overdose due to their effect of depressing the central nervous system, which can slow or stop the heart and lungs. Mixing with alcohol greatly increases this risk. Deaths from prescription opioid medications now outnumber overdose deaths from all other drugs (including cocaine and heroin), and codeine-promethazine cough syrup has been linked to the overdose deaths of some prominent musicians.



Posted May 26, 2013

Molly—slang for “molecular”—refers to the pure crystalline powder form of the club drug MDMA (3-4 methylenedioxymethamphetamine), which in pill form is known as ecstasy. Molly, which is usually purchased in capsules, has seen a surge in interest in the past few years, being celebrated frequently by popular music artists. MDMA in any form produces energy and euphoria in users but also may dangerously affect body temperature and cause confusion, depression, and sleep problems.

Users may be seeking out Molly to avoid the adulterants or substitutes known to be commonly found in pills sold as ecstasy, such as caffeine, methamphetamine, and other harmful drugs. But those who purchase what they think is pure MDMA as Molly may actually be exposing themselves to the same risks. Hundreds of “Molly” capsules tested in two South Florida crime labs in 2012, for example, contained methylone, a dangerous stimulant commonly found in “bath salts” (see video below). News reports elsewhere have reported “Molly” capsules containing cocaine, heroin, and other substances.


This page was last updated August 2015

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