New research in the scientific journal Addiction highlights a worrying trend: Deaths from fentanyl and stimulant overdoses in the United States have increased more than 50-fold since 2010. By 2021, stimulants will dominate fentanyl-related overdose cases in every U.S. state. The "fourth wave" of the opioid overdose crisis poses numerous challenges to medical staff, not least the limited effectiveness of the commonly used antidote naloxone.
Cases of fentanyl-type stimulant overdoses in the United States have increased 50-fold since 2010, signaling a "fourth wave" of the opioid crisis with racial disparities and regional differences in drug mix, a new study shows.
New research published in the scientific journal Addiction found that the proportion of overdose deaths involving fentanyl and stimulants 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.
Expert opinion
"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 Dr. Joseph Friedman of the University of California, Los Angeles. "Fentanyl contributes to the multi-substance overdose crisis, which means that people are mixing fentanyl with other drugs such as stimulants, as well as using fentanyl." "
A simplified schematic of the four waves of the overdose death crisis in the United States. Waves 1 and 2 include deaths involving commonly prescribed opioids and heroin, respectively, but not deaths involving fentanyl. 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
People who take multiple substances may also be at increased risk for overdose, and many substances mixed with fentanyl do not respond to naloxone, the antidote for opioid overdoses.
Demographic differences
The authors also found that fentanyl/stimulant 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-type stimulant overdose deaths 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 region. The rate for the general U.S. population in 2021 was 49%.
Regional drug preferences
There are also geographic patterns in fentanyl/stimulant use. 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.
The analysis illustrates how the U.S. opioid crisis began with an increase in deaths from prescription opioids in the early 2000s (first wave) and heroin in 2010 (second wave). Around 2013, an increase in fentanyl overdose deaths signaled the arrival of the third wave of the crisis. The fourth wave - fentanyl-type stimulant overdoses - began in 2015 and continues to grow.