Speedballing: The Risks of Combining Opioids and Stimulants

Speedball ingredients

A speedball involves two specific classes of drugs with opposing effects:

Stimulants increase heart rate, energy, euphoria, and alertness: ^[1][3]

• Cocaine: A powerful stimulant that blocks dopamine reuptake, causing intense euphoria and increased energy
• Methamphetamine: A longer-lasting stimulant with a more substantial effect on the CNS, commonly found in "goofballs”

CNS depressants slow down breathing and heart rate, providing pain relief and sedation: ^[1][4]

• Heroin: An illegal opioid that rapidly converts to morphine, creating a euphoric rush followed by deep sedation
• Fentanyl: A synthetic opioid 50 to 100 times stronger than morphine; while it has legitimate medical uses, it is often found in counterfeit drugs and associated with a surge in overdose deaths

Types of speedballs

• Classic speedball (cocaine + heroin) ^[1]
• Crack speedball (crack cocaine + heroin) ^[2]
• Goofball (methamphetamine + heroin) ^[3]
• Fentanyl speedball (fentanyl + cocaine or methamphetamine): While fentanyl is sometimes deliberately mixed with cocaine to create a speedball, most of the time, users are unaware the mixture contains fentanyl and cocaine. This increases the likelihood of an adverse reaction compared to those who intentionally sought out fentanyl. ^[4]
• “Calvin Klein” or CK speedball (cocaine + ketamine): A lesser-known speedball called CK (reminiscent of New York’s nightclub scene) is a snorted mixture of powdered cocaine and ketamine.

Reasons people use speedballs

The motivations behind drug use are complex and not always tied to a specific substance or combination of substances. Yet, there are common reasons people use speedballs:

• Euphoria and heightened effects: Users seek the powerful high created by the simultaneous stimulant rush and opioid sedation, which exceeds the impact of either drug alone. ^[5]
• Coping with psychosocial factors: Speedball use is often driven by attempts to manage psychosocial and social dislocation factors, such as homelessness, trauma, job disruptions, or social isolation. Users may look to speedballing as a way to alter their sense of self or attempt to escape from these harsh realities. ^[6]
• Self-medication for psychological distress: Users may rely on stimulants to lift their mood and opioids to relieve emotional pain. Using speedballs can be a coping mechanism for trauma, anxiety, or depression. ^[6]
• Prolonging or synergizing drug effects: Users combine stimulants and opioids to amplify or extend their effects, with research identifying this behavior as part of polydrug use patterns. It is reported to intensify the effects and make the euphoria last longer. ^[7]
• Counteracting opioid-induced respiratory depression: Some people who use speedballs think that stimulants counteract opioid-induced respiratory depression. This misconception increases fatal overdoses because stimulants can mask the symptoms of respiratory depression without reversing the underlying process. ^[7]
• Reducing unwanted side effects: People use speedballs believing that the contrasting effects of the two drugs will counteract each other’s unwanted symptoms or side effects. ^[8]
• Increasing desired effects: The combination of drugs produces unique subjective effects desired by speedball users. ^[3]

Why is speedballing so dangerous?

Masked overdose symptoms

The stimulant in a speedball (e.g., cocaine) counteracts the immediate sedative effects of the opioid (e.g., heroin), making the user feel more alert and less intoxicated than they are. This masking effect can lead people to take dangerously high doses of the opioid, significantly increasing the risk of fatal overdose.^[16] 

Since stimulants have a shorter half-life than opioids, as the stimulant wears off, the full effects of the depressant can suddenly overwhelm the nervous system, resulting in respiratory depression, loss of consciousness, and death. ^[17]

Increased risk of respiratory failure and cardiac arrest

Speedballing puts severe strain on both the cardiovascular and respiratory systems. Stimulants increase heart rate and blood pressure; depressants slow breathing and lower blood pressure. This antagonistic effect disrupts physiologic regulation and can result in irregular heart rhythms (arrhythmias), heart attack, or stroke.^[7]

Additionally, opioids suppress the brain’s ability to regulate breathing, and when combined with stimulants, the eventual crash can cause sudden respiratory failure.^[17]

Due to these unpredictable and deadly interactions, speedballing has one of the highest overdose fatality rates among polydrug users, leading to a significantly higher risk of death than using either drug alone. ^[18]

Emergency response

If you suspect a speedball overdose, follow these steps: ^{[19][20][21][22]}

• Evaluate hazards (check scene safety first): Do not enter if the scene is unsafe; if the scene is safe, wear gloves to reduce exposure.

• Check responsiveness (talk, shake, and sternal rub): If the person is not responding, call 911 and report a suspected overdose or yell for help if you don’t have a phone.

• Assess airway & breathing (check pulse and lift chin to open airway): If no normal breathing or only gasping, start CPR immediately:
• Give naloxone (to counteract opioids): If there is no improvement, repeat every 2–3 minutes (max four doses) and watch for aggression due to unopposed stimulant effects once Naloxone begins to work.

• Move the individual to the recovery position (if breathing resumes): This will help prevent aspiration or choking.

• Stay & monitor the individual until EMS arrives: Watch for fluctuating mental status, cardiac or respiratory arrest, agitation, and vomiting.

• Understand legal protection (through the Good Samaritan Law): Disclose a suspected overdose to the emergency response team to ensure the best care for the individual

Psychiatric effects

Over time, chronic use of speedballs leads to an inability to experience pleasure, contributing to the development of depression and even suicidality. Chronic use is mainly associated with drug-induced psychosis, characterized by hallucinations, delusions, and, in some cases, violent behavior as a result of neurochemical imbalances and repeated withdrawal cycles. ^[24]

What’s more, is that people who use speedballs also exhibit a more severe psychopathology. ^[14] Research suggests links between speedball use and high levels of antisocial behavior, bipolar disorder, and post-traumatic stress disorder (PTSD).

Physiologic effects

Because drugs cause functional and structural changes in the brain, long-term use of speedballs alters areas of the brain responsible for decision-making and impulse control, leading to memory loss, confusion, and reduced ability to concentrate. ^[18]

Speedballing is associated with impulsivity, impaired judgment, and high-risk activities, like unsafe injection practices and other risky behaviors (including unsafe sex practices), which amplifies the transmission of infectious diseases, as evident from the correlation between speedballing and higher incidences of HIV.^[23]

Addiction potential

Polysubstance use also increases the risk of addiction. Specifically, the combined use of opioids and stimulants accelerates the development of substance use disorders (SUDs). Both drugs have high addiction potential, and when used together, their synergistic effects reinforce compulsive use.

For example, cocaine’s short half-life prompts repeated dosing to sustain euphoria, while heroin mitigates stimulant-induced agitation, creating a cyclical pattern of dependence. Polydrug use starts to become common as people may incorporate and introduce other substances, such as benzodiazepines and alcohol, to modulate highs or alleviate withdrawal. ^[25]

Related: Fentanyl Use Declined in 2024, But Polysubstance Use on the Rise