The Evolution of An Epidemic
Today’s overdose crisis is dramatically different than 10 years ago.
The drug overdose crisis is worse now than ever before. While overdose deaths decreased slightly in 2018, over 72,000 Americans died of drug overdoses in 2019, an all-time high. Overdose deaths continue to rise during the COVID-19 pandemic, and 2020 is on track to be the worst year in American history.
Rising overdose deaths have followed a pattern experts call a “triple wave.” The opioid overdose epidemic began with a wave of prescription opioid overdoses, involving drugs such as hydrocodone (Vicodin™) or oxycodone (Oxycontin™, Percocet™). Over time, the class of opioid involved in overdoses shifted, first to heroin — wave two — then to synthetic opioids such as fentanyl — wave three.
This third wave — overdose deaths that involve fentanyl and related analogs — has completely transformed the overdose crisis. As fentanyl has become a primary driver of overdose deaths in this country, the populations most affected by the overdose crisis are rapidly transforming.
The Eastern United States has borne the early brunt of the fentanyl wave. This is because white powder heroin — the dominant type of heroin in Eastern states — is far easier to lace with fentanyl, another white powder, than the black tar heroin common in the west.
Using publicly-available data on all overdose deaths in the United States, we found that the fentanyl crisis is not only changing where overdose deaths happen, but also who dies of an overdose. Rapid increases in overdose deaths are mainly concentrated in states east of the Mississippi river, particularly New England and Appalachia. Yet overdose deaths are affecting more and more Americans of different backgrounds and ages, including those who are excluded from popular accounts of the overdose crisis.
“We found that the fentanyl crisis is not only changing where overdose deaths happen, but also who dies of an overdose”
In this third wave of the overdose crisis, fentanyl deaths are driving a rapidly evolving overdose epidemic among young people in the Eastern United States. Ten years ago, adults between the ages of 40 and 55 were most affected by overdose deaths, but since the emergence of fentanyl, deaths have spiked among young adults under the age of 35. Importantly, this is not a shift in the overdose crisis, but a growth. Older adults are still dying of overdose at crisis-level rates, but deaths among young adults are now higher, and growing at alarming rates. A look at fentanyl-related overdose deaths confirms that young people have been most affected by this third wave, especially in Eastern states.
While overdose deaths continue to grow across demographic groups, overdoses are killing young Black, Latinx, Indigenous, and Asian people in the US at growing rates. Overdose deaths are happening everywhere, but increasing fastest in urban areas and their suburbs.
This new sub-epidemic of the drug crisis highlights a need to change the way we think about, and act on, the overdose crisis. A few years ago, prescription opioid overdoses were a main concern. Programs like pain medication prescribing guidelines and prescription drug monitoring programs (PDMPs) were created to tackle the problem of prescription drug overdose. Pharmaceutical companies like Purdue and Johnson & Johnson were held accountable for misleading prescription drug marketing to physicians, pleading guilty to criminal charges and facing billions of dollars in penalties. The overdose crisis was popularly characterized as a rise in prescription opioid overdoses among middle-aged white people, largely due to economic deprivation, both in research and in the media. People were asking why the overdose crisis was affecting white people, and as a result, we changed our perceptions of the opioid crisis: the “War on Drugs” became “the opioid crisis,” and we became less likely to criminalize, and more likely to treat, substance use disorders.
These necessary steps have contributed to decreasing prescription drug overdoses over the last few years. However, as drug overdoses due to fentanyl and other illicit drugs rise to unprecedented levels, we face a completely new and challenging crisis. Overdose deaths affect a different set of people, who use different drugs, perhaps for different reasons. We must move beyond responding to the overdose crisis as it was 10 years ago.
While overdose deaths due to prescription opioids and heroin may be decreasing, deaths due to fentanyl continue to rise. Overdoses due to methamphetamines and cocaine — drugs more commonly used in Western states — are steadily growing, and reports of fentanyl-contaminated methamphetamine and cocaine are surfacing around the US. These trends may signal the further growth of overdose deaths in previously unaffected communities, and addressing them warrants immediate action.
If we are serious about solving this crisis, we have to tailor our solutions to fit the people most affected by it. Young people who use drugs are less likely than adults to participate in harm reduction programs, such as anonymous drug checking and syringe exchange services. Innovative programs that are driven by young people, and for young people, are urgently needed. Naloxone should be universally available at no cost in community settings like parks and libraries, in addition to pharmacies. Routine naloxone trainings should be expected at workplaces, schools, and community centers. Young people should be able to easily access medications to treat opioid use disorder without stigma or prohibitive clinical barriers. For example, pediatricians often don’t have the training or resources to prescribe medications for opioid use disorder, and may only refer adolescents to clinics that offer these medications after treatment without medication fails multiple times. Due to COVID-19 concerns, regulations that require daily dosing of these medications, urine testing, and in-person prescribing have been temporarily lifted. Continuing this beyond the pandemic would make medications for opioid use disorder much more accessible to a younger population.
If we are serious about solving this crisis, we have to tailor our solutions to fit the people most affected by it.
Reducing the stigma of drug use will be central to making sure these interventions work. Misinformation and stigma prevent doctors from prescribing medications for opioid use disorder to young people and limit naloxone availability. This same stigma causes the criminalization of drug use and elimination of important harm reduction services, such as Brown University’s cancellation of free drug testing. Supervised consumption facilities, which have been highly effective in reducing overdose deaths in other countries, are politically vilified in the US.
Reducing stigma towards people who use drugs among young people is especially important — while young people in the US are deeply socially engaged, we continue to stigmatize young people who use drugs, using offensive language like “crackhead” or “addict” in humorous or mocking contexts. This language alienates people who use drugs and those in recovery, exacerbating the stigma and discrimination they already experience. As young people, we have to acknowledge that the language we use matters. RICARES, a Rhode Island-based grassroots organization advocating for people affected by substance use, advocate that supportive communities are a human right. As young people, it is our responsibility to support each other by creating these safe, just, and stigma-free communities amongst ourselves.
As more people face overdose risk, we also must consider how well our existing response serves them. In the face of ongoing anti-Black police violence, young Black people are reluctant to call first responders in response to an overdose, for fear of a violent police response. Despite Good Samaritan Laws offering limited immunity, interactions with law enforcement can lead to charges of drug-induced homicide or may affect people’s employment, housing, or family custody. While the War on Drugs is largely decried as a failure, we continue to use the carceral system to respond to addiction. This must change.
If we are to truly get serious about turning the tide on the overdose crisis, we need to radically rethink the way we address drug use, particularly among young people. While fentanyl deaths have been mostly concentrated in the Eastern United States, these patterns are changing, and new populations face unprecedented risks of overdose death. The overdose death toll is at an all-time high, but things can and likely will become much, much worse. Bold, creative action, tailored to the communities most affected by this ever-changing overdose crisis, is the only way forward.
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Citation: Gaur DS, Jacka BP, Green TC, Samuels EA, Hadland SE, Krieger MS, Yedinak JL, Marshall BDL. US Drug Overdose Mortality: 2009–2018 Increases Affect Young People Who Use Drugs. International Journal of Drug Policy. 2020;85:102906
