General Warnings

Rising Tide of Tragedy: Exploring the Fourth Wave of the U.S. Overdose Crisis

The “fourth wave” of the U.S. overdose crisis represents a concerning evolution of the country’s ongoing struggle with substance abuse and addiction. This wave is characterized by the increasing use of illicit fentanyl, an extremely potent synthetic opioid, combined with stimulants such as cocaine or methamphetamine. Unfortunately, this deadly combination is leading to a surge in overdose deaths, posing a significant public health crisis.

The statistics are alarming, with the proportion of U.S. overdose deaths involving fentanyl and stimulants skyrocketing by more than 50-fold since 2010. In 2010, this combination accounted for only 0.6% of overdose deaths, but by 2021, it had risen to over 32%. This trend underscores the severity of the crisis and the urgent need for intervention.

Chelsea Shover, an assistant professor-in-residence at the UCLA David Geffen School of Medicine, emphasizes that this is no longer just an opioid crisis; it’s an overdose crisis that transcends opioids alone. This crisis has evolved through different waves over the years:

1.        The first wave, in the early 2000s, was marked by an increase in deaths from prescription opioids.

2.        The second wave emerged around 2010 with the shift to illegal opioid heroin.

3.        The third wave, around 2013, was characterized by an increase in fentanyl overdoses.

4.        The fourth wave began in 2015 and continues to rise, driven by the combination of fentanyl and stimulants.

Fentanyl is a synthetic opioid that is up to 50 times more potent than heroin and 100 times more potent than morphine. Its presence in the illegal drug market has made overdose prevention even more challenging.

The study reveals that stimulants have become the most common drug class found in fentanyl-involved overdoses in every U.S. state by 2021. This suggests both intentional co-use, where individuals purposefully combine fentanyl and stimulants for a desired effect and unintentional use due to the extreme potency of fentanyl.

Tragically, fentanyl/stimulant overdose deaths disproportionately affect Black and Native American communities. In 2021, stimulant involvement in fentanyl overdose deaths was notably higher among these groups, emphasizing the need for targeted prevention efforts.

Geographic patterns in fentanyl/stimulant use are also evident, with different combinations prevalent in different regions of the United States. In the Northeast, fentanyl tends to be mixed with cocaine, while in the southern and western United States, it is more commonly combined with methamphetamine.

Addressing this crisis requires a multi-pronged approach:

1.        Improving Access to Medications for Opioid Use Disorder: Medications like buprenorphine, methadone, and extended-release naltrexone can help individuals with opioid addiction. Simplifying the process for healthcare providers to prescribe these medications is crucial.

2.        Widespread Distribution of Naloxone: Naloxone, which rapidly reverses opioid overdose effects, should be readily available and accessible to all. Recently, the FDA approved over-the-counter naloxone nasal spray for nonprescription use.

3.        Contingency Management for Stimulant Use Disorder: Implementing contingency management programs, offering incentives to those struggling with stimulant use disorder, can be effective in reducing overdose risk.

4.        Fentanyl Test Strips and Monitoring: Routine use of fentanyl test strips in clinics can help identify the presence of fentanyl in drugs. This approach should extend to detecting other potentially lethal substances like xylazine.

5.        Educational Efforts: Informing the public, especially parents and young people, about the risks of polysubstance abuse and the dangers of counterfeit pills containing fentanyl and stimulants is vital.

6.        Combating the Opioid Epidemic in the Context of the COVID-19 Pandemic: The pandemic exacerbated the overdose epidemic due to factors like job loss, social isolation, and reduced access to mental health and substance use services. Efforts to address the overdose crisis should take these pandemic-related challenges into account.

In conclusion, the “fourth wave” of the U.S. overdose crisis is a grave concern, driven by the lethal combination of fentanyl and stimulants. Tackling this crisis requires a comprehensive and compassionate approach that includes prevention, harm reduction, and support for individuals struggling with substance use disorders.


Dr. Oche Otorkpa PG Cert, MPH, PhD

Dr. Oche is a seasoned Public Health specialist who holds a post graduate certificate in Pharmacology and Therapeutics, an MPH, and a PhD both from Texila American University. He is a member of the International Society of Substance Use Professionals and a Fellow of the Royal Society for Public Health in the UK. He authored two books: "The Unseen Terrorist," published by AuthorHouse UK, and "The Night Before I Killed Addiction."

Christiana Gobina (BPharm)

Pharmacist Christiana holds a Bachelor of Pharmacy degree (BPharm) from the University of Ilorin. She is a dedicated healthcare professional with passion for Pharmacovigilance and medication safety particularly in underserved communities.
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