To understand the opioid crisis, which began around 1999, it’s helpful to think of it as developing in distinct waves, each driven by different factors, and that around 2020, we moved from the third wave to the fourth wave of the opioid crisis.
Here’s how the different waves of the crisis unfolded:
First Wave: 1999 – 2007
- Driven by increase in the number of prescriptions for a new generation of opioid pain relievers containing oxycodone.
Second Wave: 2007 – 2013
- Driven by sudden restrictions in opioid prescriptions.
- In response, many patients who developed OUD turned to illicit opioids, increasing overdose risk.
Third Wave: 2013 – 2019
- Driven by an increase of fentanyl in the illicit drug supply.
Fourth Wave: 2019 – Present
- Exacerbated by the pandemic.
- Driven by stimulant misuse and polysubstance misuse.
- Complicated by an increase in co-occurring disorders.
Wave Four: Polysubstance Misuse, Stimulant Misuse, Co-Occurring Disorders
Here are the latest facts and figures from the CDC on the fourth wave of the opioid crisis, which began in 2019. We’ll start with the big-picture opioid details, then focus on stimulants, and finish this section with information on co-occurring disorders.
Fatal Overdose: Opioids, 2019-2023:
- 2019: 50,178
- 2023: 81,398
62 percent increase.
Fatal Overdose: All Substances, 2019-2023:
- 2019: 67,697
- 2023: 105,227
55 percent increase.
Stimulant overdose, 2015-2023:
- 2015: 5,526 fatalities
- 2019: 16,342 fatalities
200 percent increase
- 2023: 35,507 fatalities
117 percent increase from 2019.
Between 2015 and 2023, the data show a 542 percent increase in stimulant overdose fatalities. When combined with this report and this study from the National Institutes of Health (NIH) and the National Institute on Drug Abuse (NIDA) on methamphetamine misuse, we see the contribution of stimulants to the overdose crisis is of real concern.
Here’s what the report shows for 2015-2019, the period that immediately preceded the fourth wave:
- Methamphetamine use: 40% increase
- Frequent methamphetamine use: 65% increase
- Methamphetamine and cocaine polysubstance use: 60% increase
In addition, the NIH and NIDA report changes in various metrics measuring stimulant use:
- Ages 18-23: stimulant use increased four-fold
- Females: stimulant use increased three-fold
- Straight men: stimulant use doubled
- Native American/African American: most rapid increase in stimulant use
- IV stimulant use: increased overall
- IV stimulant use: increased most among gay men
Next, let’s look at the third phenomenon driving the fourth wave of the overdose crisis: the increase in co-occurring substance use disorder (SUD) and mental health disorders. Here’s the data from the National Survey on Drug Use and Health (NSDUH):
- 2017: 3.4%
- 2018: 3.7%
- 2019: 3.8%
- 2020: 6.7%
- 2021: 7.8%
- 2022: 8.4%
That’s an increase of close to 150 percent between 2017 and 2022.
This is a serious problem. The simultaneous presence of SUD and mental health disorders increase risk of both the SUD and the mental health disorder increasing in severity if left untreated, which can increase risk of overdose for people with SUD, and increase risk of suicide for some mental health disorders.
In addition, polysubstance misuse, which means using more than one drug at a time, can dramatically increase overdose risk. This risk is compounded by the recent trend among drug traffickers of adding the powerful, dangerous opioid fentanyl to augment the volume and euphoric effects of illicit opioids and illicit tranquilizers and stimulants. One problem – among many – this creates is that when people take stimulants, they may not keep an eye out for signs of opioid – read fentanyl – overdose. If they do recognize the signs, it may be too late to administer the lifesaving overdose reversal drug Narcan, even if it’s ready at-hand.
The Fourth Wave of the Opioid Crisis: What We Can Do
Between 2019 and 2022, we experienced a significant increase in overdose deaths. In 2023, overdose deaths decreased for the first time since 2018, which is cause for optimism. However, we need to see that decrease in context, and hope the downward movement continues. If it does, we can call it a trend: as it stands, we have a decrease over one year: good news that we hope will get better.
Now for the context.
Between 1999 and 2019, overdose deaths increased by close to 300 percent. That’s an increase of 15 percent per year. Between 2019 and 2022, overdose deaths increased by 60 percent, which is 20 percent per year. That’s clearly a larger increase than during the early years of the opioid crisis. It’s disturbing because it began from a baseline 300 percent higher than the pre-crisis numbers reported in 1999.
Between 1999 and 2023 overdose fatalities increase 524 percent.
The research tells us we need to redouble our efforts to support people with:
- Stimulant use disorders, including methamphetamine and cocaine
- Co-occurring disorders, a.k.a. simultaneous SUD and mental health disorders
- Polysubstance misuse, i.e. people who regularly use different types of drugs at the same time
In both rural and urban areas, for people with opioid use disorder (OUD), methamphetamine/cocaine use disorder, and co-occurring disorders, that means increasing access to care, increasing harm reduction programs such as mobile medication-assisted treatment (MAT) units, needle exchange programs, Narcan training and distribution programs, and MAT programs in rural and urban community clinics and health centers. Evidence shows harm reduction strategies can reduce rated of relapse, overdose, and death related to opioid use and misuse. If we follow the data and expand our level of commitment and support for people in all these at-risk groups, we can improve the lives of families, individuals, and communities in the years to come.