"The role of co-use of heroin and methamphetamine in overdose requires greater exploration. Intentional co-use of heroin and methamphetamine is increasing in the US, whether in simultaneous injection as a ‘goofball’, sequential injection or other combined modes, including smoking and snorting. Supply changes have played a part in widespread distribution of ‘ice’ or ‘cream’, a more potent and lower price Mexican-sourced methamphetamine supplanting the domestic product [10, 16].

"‘Goofball’ was originally a term for barbiturate-type drugs with the earliest mention in the literature as heroin-methamphetamine injection in 2005 [17]. Heroin and methamphetamine co-use (referred to in some locations as a goofball and in others as a speedball, which historically has been a combination of heroin and cocaine) is spreading in locations as varied as Seattle, Washington; San Diego, California; Denver, Colorado; and Dayton, Ohio [18,19,20,21]. Qualitative research has found many people who use drugs (PWUD) believe methamphetamine can prevent or reverse opioid-related overdoses [20] and reduce withdrawal severity [22]. A study in Vancouver, Canada, found that practitioners used goofballs bi-directionally, both to enhance the individual effects of opioids and methamphetamine and to control for each drug’s negative effects [23]. However, knowledge about forms of co-use of methamphetamine and heroin, particularly from recent years, is needed to understand rising mortality among people using methamphetamine."


Ondocsin, J., Holm, N., Mars, S.G. et al. The motives and methods of methamphetamine and ‘heroin’ co-use in West Virginia. Harm Reduct J 20, 88 (2023). doi.org/10.1186/s12954-023-00816-8