Overdose deaths involving stimulants such as methamphetamine and cocaine spiked dramatically from 2016 to 2017 in Philadelphia, a new report from the city’s health department found.

What’s more, officials saw an uptick in prescriptions for legal stimulants such as amphetamine, which includes the drug Adderall, used to treat ADHD.

In nearly all of the stimulant-related overdose cases, victims had also ingested an opioid, usually the powerful synthetic fentanyl.

Illicit fentanyl, which has contaminated virtually all of Philadelphia’s heroin supply, was present in nearly every overdose death in the city in 2017, and is likely driving the uptick of cocaine- and methamphetamine-associated deaths. Overdoses on only cocaine or methamphetamine, with no opioids present, have stayed relatively stable or increased just slightly since 2010.

Still, in 2017, the total of cocaine-related fatal overdoses jumped by 47 percent, to 597 from 2016. Of those, 82 percent involved an opioid.

Just 72 people died of methamphetamine-related overdoses in 2017 — but that was a 112 percent increase from 2016, according to the report. Of the meth-related deaths, 93 percent also involved an opioid.

Why would a person using fentanyl — known to be highly sedating — also take a stimulant?

Fentanyl is a much more powerful sedative than heroin, and some users also take methamphetamine or cocaine to remain conscious. Methamphetamine is a more powerful stimulant than cocaine, and its effects last longer. And nationally, over the last several months, doctors and law enforcement officials have been warning of a rise in meth use that’s being overshadowed by the intense focus on the opioid crisis.

The health department has also interviewed opioid users who began using methamphetamine to stay awake overnight, said Kendra Viner, the city’s Opioid Surveillance Program manager.

Coming off fentanyl sends a person into withdrawal so much more quickly than heroin that users who fall asleep after using fentanyl risk waking up in “just misery," Viner said. When a person is deep into opioid addiction, they are using the drug not to achieve a pleasurable high, but to stave off the painful symptoms of withdrawal.

Other drug users may be looking to take a “speedball,” the colloquial term for the heroin-cocaine combination that’s said to produce a unique euphoria. Drug users could think they are buying cocaine and heroin separately, but instead of heroin winding up with the deadlier fentanyl. Cross-contamination during drug packaging is also a possibility, Viner said.

The report also found that sales of amphetamines, such as Adderall, a popular ADHD drug, increased by 617 percent between 2000 and 2017 in Philadelphia, and pharmaceutical companies that make stimulants are spending more on free meals for doctors, presumably to bring their attention to the product.

Overdoses involving prescription amphetamines make up a small fraction of Philadelphia’s overdose death toll, but rose 158 percent between 2014 and 2017. Most of those deaths also involved opioids.

Though the proliferation of painkillers has been widely blamed for the opioid overdose crisis, it’s unclear whether a jump in amphetamine prescriptions correlates with a jump in stimulant-related overdose deaths — and how many people who were legally prescribed stimulants will go on to develop an addiction.

“I’m very reluctant to make the conclusion on the natural history of how someone progresses from a prescription stimulant to an illicit stimulant,” Viner said. “That’s probably happening, but we don’t know how that transition happens or when it happens. It’s possible these two things are happening in parallel — the increased prescribing of stimulants" and the uptick in stimulant overdose deaths. "Given what we know about various drug epidemics we’ve had over the last century, it’s unlikely there’s no relationship.”

Still, Viner said, the rise in stimulant deaths speaks to the volatility of Philadelphia’s drug supply — and how fentanyl has upended what was once a relatively stable supply.

“Up until a few years ago, people knew what they were getting, and drugs weren’t being mixed in the way that they are,” she said.

Jim Garrow, a health department spokesperson, said Monday’s report was the department’s “first foray into this world of stimulant use."

Viner said the department will likely begin to reach out to doctors who prescribe high volumes of stimulants to educate them about the risks of overprescribing — and to warn patients about the risk of fentanyl in the drug supply.

“For us, it’s very much, ‘What the hell is going on out there?’” Garrow said. “Let’s get a feel for that — which will inform a lot of what this response grows into.”