"Goofballing": An Emerging Threat With Clinical Challenges

The coinjection of methamphetamine and opioids, known as "goofballing," is an emerging practice among people who inject drugs. This combination poses significant clinical challenges due to the opposing pharmacological effects of stimulants and depressants. The increasing prevalence of this practice, particularly in North America, raises significant concerns regarding its impact on public health and patient management.

The authors report the case of a 48-year-old man admitted to the intensive care unit with suspected sepsis after intravenous heroin use. During methadone substitution therapy, the patient developed hyperthermia, diffuse myalgia, and mild somnolence. Physical investigation revealed no evidence of infection. Toxicological analyses were conducted on blood and urine samples using targeted and nontargeted screening methods.

Toxicological analyses revealed the presence of methamphetamine, amphetamine (a metabolite of methamphetamine), morphine, codeine, methadone, and EDDP in both blood and urine. The presence of 6-acetylmorphine in the urine confirmed recent heroin exposure. No other substances were detected in any sample. The patient was later treated for coinjection of heroin and methamphetamine, which supported the diagnosis of goofballing-induced hyperthermia rather than sepsis.

This case highlights the diagnostic challenges associated with the "goofball" phenomenon. The coadministration of methamphetamine and heroin can lead to severe atypical toxicological symptoms. Health care providers should be aware of this emerging practice to ensure rapid diagnosis and appropriate management. Public health initiatives should focus on harm reduction strategies to mitigate associated risks.