Deaths from fentanyl and stimulant overdoses in the United States have increased 50-fold since 2010, a UCLA study found, marking a worrying "fourth wave" of the opioid crisis. The rise in polypharmacy creates unique medical challenges, with minorities disproportionately affected and regional differences in drug combinations.
The trend marks the fourth wave of the U.S. opioid overdose crisis, which began with deaths from prescription opioids early this century and has continued with deaths from other drugs since.
New research led by UCLA found that the proportion of fentanyl and stimulant overdose deaths in the United States has increased more than 50-fold since 2010, from 0.6% (235 deaths) in 2010 to 32.3% (34,429 deaths) in 2021.
By 2021, stimulants such as cocaine and methamphetamine had become the most common drug class in overdoses involving fentanyl in states across the United States. The rise in fentanyl/stimulant deaths is the "fourth wave" of America's long-running opioid overdose crisis, with deaths still rising sharply.
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"We are now seeing that the use of fentanyl and stimulants is quickly becoming a dominant force in the opioid overdose crisis in the United States," said lead author Joseph Friedman, an addiction researcher at the David Geffen School of Medicine at UCLA. "Fentanyl fueled the multi-substance overdose crisis, which means people are mixing fentanyl with other drugs such as stimulants." "
The findings were published Sept. 13 in the peer-reviewed journal Addiction.
A simplified schematic of the four waves of the overdose death crisis in the United States. Waves 1 and 2 included deaths involving commonly prescribed opioids and heroin, respectively, but not fentanyl-related deaths. Waves 3 and 4 showed different trends for deaths not involving fentanyl and deaths involving stimulants, respectively. Data comes from CDCWONDER. Source: Friedman and Shover, 2023, doi:10.1111/add.16318
The analysis illustrates how the U.S. opioid crisis began with an increase in prescription opioid deaths in the early 2000s (Wave 1) and heroin (Wave 2) in 2010. Around 2013, an increase in fentanyl overdose deaths signaled the arrival of the third wave of the crisis. The fourth wave - overdoses of fentanyl along with stimulants - began in 2015 and continues to grow.
Compounding the problem, people who consume multiple substances may also be at increased overdose risk, and many substances mixed with fentanyl do not respond to naloxone, the antidote for opioid overdoses.
Demographic and Geographic Trends
The authors also found that fentanyl overdose deaths disproportionately impact racial/ethnic minority communities in the United States, including Blacks, African Americans, and Native Americans. For example, in 2021, the incidence of fentanyl overdose death was 73% among non-Hispanic black or African American women aged 65 to 74 living in the western United States, and 69% among black or African American men aged 55 to 65 living in the same area. In 2021, this proportion among the general population in the United States was 49%.
Fentanyl use also has geographic patterns. In the northeastern United States, fentanyl is often mixed with cocaine; in the southern and western United States, fentanyl is most commonly mixed with methamphetamine.
"We suspect this pattern reflects the increasing availability and preference for low-cost, high-purity methamphetamine across the United States, as well as a pattern of illicit cocaine use that is deeply entrenched in the Northeast and has so far not been completely replaced by methamphetamine in other parts of the country," Friedman said.