An Update on the Epidemiology of Tusi (“Pink Cocaine”)

Abstract

Purpose of Review

Tusi, also known as “pink cocaine,” has emerged across nightlife scenes in Latin America, Europe, Australia, and the United States (US). Tusi is typically a drug mixture containing ketamine and 3,4-methylenedioxymethamphetamine (MDMA). Due to tusi’s inconsistent chemical makeup, surveillance and harm reduction efforts have proven difficult for researchers and consumers alike. This review synthesizes evidence from peer-reviewed literature, drug checking programs, toxicology reports, and law enforcement data published between 2020 and 2025 to characterize tusi’s composition, epidemiology, and associated risks.

Recent Findings

Drug checking services in various countries have identified ketamine and MDMA as the main components of tusi with additional substances often added (e.g., synthetic cathinones, cocaine, methamphetamine) in varying combinations. Laboratory data from Spain show that ketamine concentrations in tusi have increased over time. Surveys in Spain and Colombia highlight increases in initiation, polysubstance use involving tusi, and misclassification of its contents. Toxicology and case series reports indicate that harms associated with use stem largely from polysubstance mixtures rather than any single component, yet morbidity and mortality data typically focus on individual drugs detected.

Summary

Tusi exemplifies a novel trend in emerging drugs: it is a blend of substances rather than a single compound, with its identity shaped by its distinctive color and association with nightlife. Its inconsistent composition and frequent co-use with stimulants and dissociatives elevate risk while complicating surveillance. Standardized survey items, expanded drug checking, and improved toxicological monitoring are needed to track and respond to this evolving mixture in the global drug supply.

Introduction

Tusi, also known as “pink cocaine,” is an emerging drug concoction in nightlife scenes. Although its name mimics the pronunciation of “2C,” referring to a group of psychedelic phenethylamines discovered by Alexander Shulgin [1], most modern tusi concoctions do not contain 2C series drugs, leading to confusion among drug researchers, consumers, and the general public [2, 3]. Tusi typically consists of a pink powder mixture of ketamine and 3,4-methylenedioxymethamphetamine (MDMA), with occasional additives including cocaine, amphetamines, caffeine, and/or synthetic cathinones, but rarely 2C-B or other 2C series drugs [2–6]. Tusi is usually snorted, though oral use has been documented in nightlife settings, especially across Latin America [4, 7]. This concoction first appeared in Latin America before spreading to European and US nightlife scenes, where both drug checking services (DCS) and law enforcement agencies have noted its emerging presence [3–5, 7]. Media attention and coverage of its use by celebrities have appeared to amplify the visibility and demand for tusi, even as its composition remains highly variable and frequently misrepresented [2, 8, 9].

Despite this growing awareness of tusi from public health and law enforcement sectors, more studies are needed to summarize the available data on tusi. We reviewed the current peer-reviewed and gray literature published between 2020 and 2025 to characterize emerging data on tusi’s composition, prevalence, and associated harms. This review brings together toxicological, epidemiologic, and harm reduction information to situate tusi within today’s changing landscape of synthetic drugs and polydrug use. We focus on five areas: tusi’s global diffusion, chemical composition, use patterns, associated harms, and implications for drug surveillance and public health efforts.

Market Emergence and Global Diffusion

Tusi first appeared in Colombia in the late 2000 s before spreading beyond the region [4, 8]. Following this emergence in the Colombian nightlife scene, tusi began to appear in Chile, Argentina, and Uruguay, and eventually in Europe and North America, according to the United Nations Office on Drugs and Crime (UNODC) [4]. Although, of note we describe tusi’s market emergence as more of a diffusion of an idea rather than importation of a drug because tusi appears to often be manufactured locally [10]. Barbaro and Bouchard [8] noted that tusi’s popularity has more to do with its image than its chemistry, as its appeal seems lie in its color and branding rather than a consistent drug formula. Initially, the pink coloring was reportedly used to mask 2C-B’s harsh taste and make snorting the powder more palatable. However, as the demand for 2C-B increased, suppliers reportedly began cutting the product with other substances like ketamine and MDMA in attempt to mimic 2C-B’s effects [8]. Eventually 2C-B disappeared from the formulation, but the pink color remained as a selling tactic, which served as clear branding for tusi that further streamlined its visual appeal and growing popularity [8].

The International Narcotics Control Board (INCB) now lists tusi among colored synthetic powders sold as “party” or “designer” drugs, indicating greater global recognition of its spread as reported by various drug control agencies [11]. The European Union Drugs Agency (EUDA) included tusi under “other drugs” in its 2025 European Drug Report [5], which noted 74 tusi-labeled powder samples submitted by six DCS in six EU Member States in 2024. EUDA characterized these powders as tusi based on the products containing a chemical makeup of mixtures of ketamine, MDMA, and a third substance (cocaine, amphetamine, or new psychoactive substance [NPS]), in addition to their pink color and sweet smell [5]. Spain and Italy reported more tusi seizures than any other EU countries that submitted seizure data to the report [5]. In Spain, it was reported that at least two criminal networks trafficking tusi were disrupted by law enforcement [5]. Of note, however, information is lacking regarding whether samples seized in these countries were indeed marketed as tusi. While the EUDA report did not discuss tusi trafficking specifically, it did note that most ketamine seized in Europe comes from India, with some also traced to Pakistan and China [5].

In the United States (US), the US Drug Enforcement Administration (DEA) documented multi-kilogram “pink powder” seizures in both New York City (NYC) and off the coast of California in 2024 [12, 13]. The US Coast Guard also seized 140 pounds of a pink powder believed to be tusi off the coasts of Mexico and Central and South America in 2024, which were linked to people in California who likely intended to distribute the drug concoction [9]. DEA data suggests that most tusi encountered in the US is sold in small retail quantities rather than in the larger quantities typically associated with organized trafficking operations [6, 14]. By 2024, DEA laboratories had tested about 960 seized pink powder samples, with only four containing any 2C-B [6]. The DEA’s 2024 National Drug Threat Assessment (NDTA) identified the Sinaloa Cartel as a key player taking advantage of new drug trends by producing and distributing tusi [15]. The report also noted that while no tusi laboratories had been seized in Mexico, the Sinaloa Cartel was capable of importing large amounts of ketamine from China to support regional production [15]. The DEA’s 2025 NDTA expanded on this finding, suggesting that the Sinaloa Cartel had used the tusi brand to create mixtures that combined ketamine with cocaine, methamphetamine, and/or other substances [14].

Composition of Tusi

Drug checking programs across Latin America and Europe have found that tusi’s chemical makeup varies substantially among region and batches, including differences in detections and quantities of substances like ketamine and MDMA [10]. Nevertheless, programs like Échele Cabeza in Colombia and Energy Control in Spain have consistently described ketamine and MDMA as the main ingredients in tusi samples, with 2C-B rarely detected [16, 17]. Reflecting widespread misclassification, individuals who use tusi have reported snorting 2C-B, initially believing it was tusi [16].

Échele Cabeza analyzed 2,868 samples submitted for drug checking in 2021, most of which were collected in the three largest cities in Colombia, and 228 (7.9%) of which were sold under the name tusi [16]. Of the samples sold as tusi, 162 were sent out for additional laboratory testing, which identified a variety of substances such as ketamine, stimulants (MDMA, methylenedioxyamphetamine [MDA], amphetamine, methamphetamine, N-ethylpentylone, cocaine, and caffeine), psychedelics (2C-B and 2,5-dimethoxy-4-bromoamphetamine [DOB]), local anaesthetics, opioids (tramadol and oxycodone), and other medicinal drugs (carbamazepine, sertraline, paracetamol, and metronidazole) [16]. Only three of the samples sold as tusi had 2C-B detected, all of which were in combination with ketamine, MDMA, DOB, and caffeine [16].

Energy Control in Spain [17] tested 470 samples sold as tusi from 2020 to 2024, which provided insight into trends in shifts in the composition and presence of tusi during this timespan. In 2020, only five tusi samples were submitted, while 201 were submitted in 2024, indicating an increasing presence in Spain [17]. Within the 470 samples analyzed, 36 different substances were detected; ketamine (93.2%) and MDMA (92.1%) were the most common, and 2C-B was only detected in 3.6% of the samples. Energy Control specifically began monitoring two categories of tusi mixtures: “ketamine + MDMA only” and “ketamine + MDMA + other substances.” The “adulterated” tusi mixture of “ketamine + MDMA + other substances” was more common than the “pure” dual-drug tusi mixtures from 2020 to 2023, with 20% containing the “ketamine + MDMA” only mixture [17]. However, a shift occurred in 2024, with nearly half of the samples identified as having the basic “ketamine + MDMA only” combination [17]. Given this increasing presence of the “ketamine + MDMA” only mixture, Energy Control also tracked the percentages of ketamine and MDMA in the tusi samples submitted of these “pure” dual-drug tusi mixtures. From 2020 to 2024, the ketamine proportion steadily increased from 28% to 48% [17].

Of the 2,093 samples submitted as “2C” to the Instituto de Salud Publica de Chile in 2022, 99% were ketamine-based and only 13 samples were identified as actual “2C,” showing how common mislabeling has become [4]. However, it should be noted that reports did not specify whether these claims were written or made verbally. Written labels would clearly mislead consumers, but in spoken form, “2C” and “tusi” sound similar enough to be confused.

The Australian Federal Police (AFP) first identified tusi in a 2020 seizure of 154 g [18]. Between March and July of 2024, 133 kg of tusi was seized by the AFP, which mainly consisted of ketamine and MDMA with varying purities [18]. Later that same year, the AFP began an investigation to halt 252 kg of tusi from being trafficked into Australia from Europe via air cargo consignment [18]. The Victorian Pill Testing Service in Australia further reported that seven samples were submitted to their DCS between December 2024 and September 2025 labeled as tusi [19]. This DCS defined tusi as “ketamine + MDMA with or without caffeine” for it to be “identified as the expected drug” [19]. In 2023, CanTEST disseminated harm reduction messaging reporting that a product sold as 2C-B turned out to contain a ketamine-MDMA mixture instead [20].

In 2023, Palamar [3] analyzed lab data from DrugsData.org, a voluntary program that once allowed people to mail-in samples for testing through a DEA-approved laboratory. Out of 19 US samples labeled as tusi or pink powders collected between 2019 and 2022, almost all contained ketamine (94.7%), most also contained a ketamine precursor called 1-[(2-chlorophenyl) (methylimino)methyl] cyclopentanol (84.2%), and 63.2% also contained MDMA. However, DrugsData stopped accepting new submissions after 2024, and because the program relies on voluntary submissions, the samples reflect what a small, self-selected group of participants chose to mail in, so results may be unrepresentative of patterns in the broader drug supply.

Patterns of Use: Evidence from Survey Data

While DCS results allow for the monitoring of prevalence and drug components within tusi, most of what researchers know about tusi-related behavior mostly comes from survey data (self-report). In Colombia, the harm reduction group Échele Cabeza has been monitoring how tusi use spreads through nightclub scenes and youth social circles. They gather information through anonymous nightlife-based surveys with partygoers to learn more about its perceived effects and how it is used [16]. In 2021, among the 186 participants who submitted tusi samples in Colombia, 61.2% reported that they use tusi once a month or more often, and 25% reportedly used it weekly or more often [16]. Most people who reported tusi use were under 30 years old (72.6%) [16]. Participants also often reported intentional co-use of poppers, alcohol, MDMA, and cocaine in combination with tusi [16]. Reports from Échele Cabeza in Colombia relay that tusi’s popularity may be related to its gradually lowering cost: in 2021, it reportedly sold for about $10 USD, whereas a gram previously was reported to cost $70 USD in 2012 [16]. However, a gram of tusi has been reported to cost €67 (~$78 USD) in Luxembourg, so its price point does not appear to be consistent throughout different regions [21]. However, we must keep in mind that cost may be related to the drugs and amounts of drugs present in each batch.

In self-report data collected from 2020 to 2024 by Energy Control in Spain [17], 285 (20.2%) of 1,412 participants surveyed reported using tusi in the past 12 months. Participants were also asked which of the substances they had used in the past 12 months were being used for the first time, and 56.3% reported recent first-time tusi use [17]. Of all the substances listed in the survey, tusi had the highest prevalence of first-time use and an average age of initiation of 24 years of age [17]. The main activity participants reported engaging in while using tusi was partying/clubbing (84.6%), and the main locations of use were nightclubs (51.2%) and raves (42.5%) [17]. Most participants reported using tusi between one and five times in the past year, and the most common consumption method was snorting small “bumps” [17]. Despite tusi containing a mixture of various substances, intentional polysubstance use was reported frequently, with 64.2% reporting they “always mixed tusi with other substances” and 13% reporting that they “almost always” combine it with additional outside substances [17]. Participants were also asked to relay what they believe tusi’s composition consisted of, and most reported that they thought it contained MDMA (68%), followed by ketamine (67.4%), 2C-B (41.8%), and/or cocaine (36.1%). Additionally, 17.2% believed tusi was “its own drug,” and 8.1% said they had no idea what it contained [17].

In the first US study to measure tusi use among nightclub attendees, Palamar et al. [7] asked adults entering nightlife venues in NYC (N = 1465) to take a 10-minute survey with the option to also provide a saliva sample [7]. Self-report survey data estimated that 2.7% of nightclub attendees in NYC used tusi in the past year [7]. Individuals who self-reported MDMA (adjusted odds ratio [aOR] = 6.59), ketamine (aOR = 3.44), and 2C-series drugs (aOR = 14.82) were at higher odds for self-reported tusi use [7]. Saliva sample analysis revealed those reporting past-year tusi use were more likely to test positive for cocaine, ketamine, MDMA, methamphetamine, and/or synthetic cathinones [7]. Drugs detected, however, were often not reportedly used by participants which could suggest unintentional exposure, although it is unknown whether such exposures were directly linked to tusi use. Relatedly, 41.7% of whom self-reported tusi use did not report ketamine use in the past year, underscoring the degree of misclassification of reported ketamine use in survey-based research among people who use tusi. The study also found that Hispanic participants reported a higher prevalence of tusi use (aOR = 5.10), which may indicate social or cultural links to its Latin American origins [10].

Most US and international drug surveys still do not query tusi (or “pink cocaine”) use. This omission may lead people with histories of tusi use to either not report use at all or to report individual tusi components from broader categories such as stimulants or hallucinogens [4, 7]. As Palamar [3] points out, this gap regarding surveys leads to a lack of important data on tusi use. This omission in some respects reproduces misclassification patterns seen during the “ecstasy/Molly” era, when adulterated ecstasy was misrepresented as pure MDMA, leading to overestimates of MDMA use and underestimates of use of common adulterants such as synthetic cathinones (via unintentional exposures) [22]. This may also inflate reported use of chemically overlapping substances such as ketamine, cocaine, or 2C-B, as people who consume tusi may mistakenly attribute their use to other categories or fail to recognize their exposure altogether, thereby distorting surveillance estimates across multiple drug classes.

Recent improvements in survey design include explicit item differentiation between tusi and 2C series compounds implemented by Palamar et al. [7], who also provide clear explanatory text distinguishing tusi from 2C compounds prior to the survey items [7]. However, because many individuals remain unaware of their product’s true composition, biospecimen testing in the same study still revealed unreported exposure to cocaine, ketamine, or methamphetamine, and it is unknown whether this was linked to tusi use [7]. Without standardized terminology and biological verification, prevalence and risk of tusi use likely remain systematically underestimated.

Associated Morbidity and Mortality

People who use tusi describe a wide range of effects, from euphoria and disinhibition to dizziness, confusion, hallucinations, vomiting, loss of reflexes, and short periods of unconsciousness [2, 16]. These health risks are similar to what is seen when stimulants and dissociative drugs are used together [2]. These combinations can lead to dangerously high body temperatures, breathing problems, and heart failure [2]. Data from America’s Poison Centers [23] recorded five exposures to “pink cocaine” across four states between January and October 2024. All required medical attention, three resulted in hospitalization, and one possible death was noted [23]. It is possible that the pink color and branding often make people who use tusi think the product is safer than it really is [2]. Some consumers intentionally combine stimulants and dissociatives to “balance” the effects, similar to the common concoction called “cK” (a mixture of cocaine and ketamine) [24], but combinations like these can increase stress on the heart and nervous system [4, 7, 25, 26].

The Florida Department of Law Enforcement identified eight colored powder ingestion related overdose deaths in South Florida [27]. The case series from Miami-Dade County by Moore et al. [27] analyzed 14 mostly pink powders which were revealed to all contain ketamine plus MDMA, MDA, cocaine, methamphetamine, oxycodone, alprazolam, eutylone, lidocaine, diphenhydramine, and/or loratadine. Toxicology results from decedent blood were compared to the composition of the drugs found at the scene of death, and decedents often had additional drugs in their blood that were not detected in the pink powders. For example, there were cases in which fentanyl (in high levels) and norfentanyl were detected in decedents, but fentanyl was absent from in the product found at the scene of death [27]. These findings are important as they suggest that people who use tusi may be at risk for fentanyl exposure and drug overdose, even when drugs like fentanyl are not in the tusi used.

In United Kingdom, deaths involving ketamine mixed with MDMA or cocaine have steadily increased from 1997 to 2019 [28]. In Thailand, a product sold as “K-powdered milk” was linked to 13 confirmed deaths in 2021 [4]. Tests showed that it contained a mix of ketamine, diazepam, caffeine, and tramadol [4]. No tusi-specific deaths were reported in Latin America or Europe through 2022 [4], but this may be due to how deaths are categorized rather than a lack of harm related to tusi use. The INCB has also noted an increase in deaths linked to synthetic powder mixtures containing ketamine and MDMA analogs, which are similar to the combinations found in tusi [11].

Toxicology systems often classify deaths based on the substances detected (e.g., ketamine, MDMA, cocaine, fentanyl), but usually not the brand name of a mixture like tusi [29, 30]. If a death involves ketamine + MDMA, it will likely be coded as an unintentional poisoning or multiple drug toxicity contributed to hallucinogen (ketamine) + stimulant (MDMA) but not tied to the actual drug combination name tusi [29]. This lack of specificity leaves it difficult to monitor tusi-related morbidity and mortality, especially without scene investigation details like the presence of a pink powder. This is somewhat similar to the early years of the US fentanyl crisis, when health systems struggled to keep up with the new drug mixtures entering the market and misclassification of drugs used occurred (e.g., heroin recorded as the cause when it was not yet known that the heroin contained fentanyl) [31, 32]. The absence of tusispecific morbidity and mortality reports is a current blind spot in surveillance. Tusi’s unpredictable contents, rising ketamine levels, and common use alongside other drugs create conditions that elevate overdose risk while remaining difficult to track in official mortality systems.

Conclusion

Tusi presents a new trend in the emerging drug market. Although NPS are typically new laboratory-synthesized compounds, tusi has shown that novelty can come from the combination of existing drugs to create a new concoction in the illicit drug supply. Surveillance systems must recognize that new drug trends may arise as not only from entirely new substances, but also from mixtures of existing drugs, and must adapt to identify and monitor these trends that do not fit traditional drug categories. For tusi specifically, its nickname (“pink cocaine”) and pink coloring only increase the public’s confusion regarding its actual composition [8, 33]. Even with no stable formula and batch variability, tusi still holds the popularity and aesthetic appeal of cocaine-like powders. This disconnect between what tusi is referred to as, how it looks, and what it contains, complicates both epidemiologic measurement and risk communication.

Laboratory data indicate that ketamine levels in tusi have been increasing, which not only enhances the potential for stronger dissociative effects but also potentially elevates the risk of harm if consumers are unknowingly using this dissociative drug [4, 17]. It is likely that many people who use tusi are unaware of the medical risks linked to ketamine, including its addictive potential and the bladder and urinary tract damage seen in people who use frequently [17]. From a harm reduction standpoint, knowing how much of each substance is present in a drug sample is as important as knowing which drugs it contains, yet to our knowledge, only one study has quantified its mixtures [17]. The chemical variability of tusi makes it difficult for people who use drugs, healthcare providers, and public health systems to assess risk or know how to respond during an emergency. These challenges highlight why clearer monitoring and communication strategies are needed as tusi continues to evolve in the drug market.

Improving surveillance and data accuracy begins with refining definitions to clearly distinguish tusi from other substances. Surveys must incorporate clearer descriptors of tusi and related powders. Existing national and international survey frameworks rarely include specific items for “tusi,” “tucibí,” or “pink cocaine,” possibly leading to systematic misclassification. Describing tusi explicitly (e.g., as a pink/colored powder commonly containing ketamine and MDMA) would help differentiate it from 2C series and cocaine products. As demonstrated in nightclub studies, pairing self-report data with biological verification (oral fluid or hair analysis) is essential to identify unreported exposures and correct for underestimation in self-report [7, 10]. In addition, the INCB recommends expanding DCS services, improving precursor chemical monitoring, expanding international data sharing, and public education campaigns clarifying that “pink cocaine” is not related to cocaine or 2C-B [11]. These measures may help modernize surveillance and make it more responsive to how tusi and other emerging NPS mixtures are produced and sold.

Supply-level tracking of tusi is also needed. While the majority of tusi-labeled samples analyzed in Latin America, Europe, and the US contained ketamine and MDMA [4, 5, 14, 16, 17], the inclusion of adulterants such as tramadol, lidocaine, or methamphetamine should be considered for monitoring as well. Systems are rarely in place to be able to track an emerging drug trend such as tusi, but DCS provides a unique infrastructure for real-time detection of these changes. Programs like Échele Cabeza in Colombia, Energy Control in Spain, and the Trans-European Drug Information network have shown that drug-checking services can fill this gap [16, 17, 34]. Although, it is the responsibility of such DCS to rapidly disseminate their findings. Results must be widely shared with the public, along with education regarding both prevention and harm reduction. These steps can help create early warning messages that connect lab findings with real-world use perspectives. Expanding similar programs in the US could help detect harmful drug mixtures sooner.

Data Availability

No datasets were generated or analysed during the current study.