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Cocaine-related overdose deaths are on the rise across the US, a federal report finds, but that’s largely thanks to heroin and its deadly chemical cousin, fentanyl.

After 2010, despite continued declines in use, overdose deaths among cocaine users have shot up more than 60%, killing about 7,000 people in 2015.

“All of the other indicators suggested that cocaine was on the decline — people reporting cocaine use in the last year, supply of cocaine, production of cocaine — those were all moving in line and declining,” said Christopher Jones, a senior policy researcher at the US department of Health and Human Services who led the newly-reported study.

Nevertheless, cocaine overdose deaths have steadily mounted nationwide. So Jones looked more closely at the numbers. He found that the percentage of cocaine overdose deaths involving any opioid, the family of painkiller drugs that includes heroin and much-abused pharmaceuticals such as Oxycontin, increased from around 29% in 2000 to 63% in 2015. Of these recent deaths involving opioids, heroin and synthetics like fentanyl contributed to roughly 81%.

“You really see significant declines where no opioid is involved,” Jones told BuzzFeed News. “But when you look at what role heroin or synthetic opioids play in those deaths, it’s really significant.”

The changes have come amid what public health officials call an “epidemic” of opioid overdose deaths. In 2015, more than 33,000 people died nationwide due to misuse of opioids — the highest number ever recorded — almost the number of people killed by car crashes. Heroin use has more than quadrupled since 2010.

Of particular concern are synthetic opioids in the fentanyl family. Fentanyl is 30 to 50 times more potent than heroin, and some fentanyl-derived compounds are even stronger, 100 times more potent than fentanyl — meant for tranquilizing large zoo animals. “These are substances equivalent to a few grains of salt,” Russ Baer, a spokesperson for the Drug Enforcement Agency, told BuzzFeed News. “Fentanyl and fentanyl compounds are our biggest concern right now. It's our deadliest concern.”

The apparent rise in combined use of cocaine and opioids itself is not new. But the added possibility of fentanyl use has increased the risk of overdose significantly.

“Historically, if you look at patterns of drug use, it was not uncommon to hear about people who would use an opioid and a stimulant together — it used to be called a speedball — heroin and cocaine or heroin and methamphetamine,” Erin Artigiani, deputy director for policy at Center for Substance Abuse Research at the University of Maryland, told BuzzFeed News.

Initial results in a study she is leading in New Hampshire have shown that roughly 37% of urine specimens from people who were determined to have died of a fentanyl overdose had cocaine in them, too. “Now that we’ve seen a shift in many places to heroin or fentanyl with heroin, or just fentanyl with something else in it, that’s certainly increasing the risk,” Artigiani said.

Others may be inadvertently consuming opioids. Jones, who headed the study, cited another recent study out of British Columbia showing that a significant number of people who were coming into treatment for meth or cocaine use tested positive for fentanyl. Another recent cluster of overdoses in New Haven, Connecticut, happened because people thought they were using cocaine that actually turned out to be fentanyl.

“If you’re someone who primarily uses cocaine and doesn’t use opioids, you’re going to be extra susceptible to the respiratory depressive effects of fentanyl,” said Jones. “If you have no tolerance to those effects, you’re at really high risk for an overdose.”

A potential solution would be to get naloxone, the opioid overdose antidote, into the hands of more people. While cocaine users may not think they’re at risk, Jones said, they increasingly might be. “This shows we’ve really got to broaden the group of people who we think might be in danger.”

LINK: The US Is Opening Its First “Safe Injection Facility” For Heroin Addicts

LINK: There’s Been An “Unprecedented” Wave Of Deaths From Drug That Killed Prince, Feds Say

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