Unintentional Fentanyl Overdoses Among Cocaine Users: A Novel Framework to Identify "Powder and Rock Confusion"

Session Description: This session introduces an under-recognized overdose risk pathway among individuals who use cocaine: unintentional fentanyl exposure due to substance misidentification, or what we call "powder and rock confusion." Drawing on five years of fatal overdose data from King County, Washington, this presentation highlights a subset of deaths in which individuals with no known opioid use history died after using fentanyl believed to be cocaine. These cases are not the result of deliberate fentanyl-laced cocaine but reflect visual misidentification at the point of use or sale. Participants will learn how to apply a scene-integrated toxicological framework to identify similar deaths in their own jurisdictions using available data sources such as toxicology, scene evidence, and substance use history. The session will also discuss how these findings can inform targeted harm reduction messaging, outreach strategies for stimulant-using populations, and clinical conversations with patients who do not report opioid use. Takeaways include: a replicable method for identifying unintentional fentanyl deaths among presumed cocaine users; red flags to look for in toxicology and scene evidence; and public health messaging adaptations that acknowledge stigma and improve engagement. This presentation emphasizes the power of cross-sector collaboration between forensic professionals, public health agencies, and community partners to detect and respond to hidden overdose trends-ultimately saving lives.