I have frequently explored drug overdose from the perspective of treatment professionals. For example, I have written on the stigma surrounding overdose (especially among teenagers), myths around overdose, and how to recognize the signs of an overdose. Unfortunately, over the course of my career as a counselor and interventionist, the rates of overdose in the United States have only increased. Overdose deaths rose in the United States from 38,643 in 2010 to 106,719 in 2021, and while there has been a slight decrease in overdose deaths since then[1], the nature of overdose seems to be changing, which has prompted researchers to suggest that we are entering “the fourth wave” of overdose crisis in the USA.
What is the fourth wave of the overdose crisis, and how does it differ from what has come before? Below, I will explore America’s recent drug crisis by looking specifically at opioids such as fentanyl in order to understand this current wave of overdose across our nation. In addition, I address key ways in which we can begin to mitigate this tragedy as mental health professionals and practitioners.
The Opioid Crisis and Beyond
At the end of 2021, it was reported that over one million people had died in the United States from a drug overdose since 1999.[2] What led us to this startling place?
Most experts point to the introduction of the powerful drug OxyContin into the American market as the start of this spate of overdose deaths. OxyContin was approved by the FDA in the mid-1990s and was promoted by pharmaceutical companies as an effective and safe painkiller. According to Harvard professor of public health Dr. Howard Koh, this was a failure on the part of regulatory systems in the US because the pharmaceutical company that originally promoted OxyContin was later shown to have used a fraudulent description of the drug as “less addictive than other opioids.” The profit motive of the pharmaceutical industry remains unchanged.
Dr. Koh describes the volume of deaths linked to the introduction of OxyContin as “the first wave” of the overdose crisis in the USA. “Then came a second wave of deaths from a heroin market that expanded to attract already addicted people. More recently, a third wave of deaths has arisen from illegal synthetic opioids like fentanyl.”[3] As of 2022, we had seen three waves of overdose as a result of the introduction of such strong prescription opioids: first legal prescription drugs, then illegal street drugs, and finally illegal synthetic drugs which mimic the effects of the prescription drugs with none of the regulation.
The Fourth Wave
This recent fourth wave of the crisis is marked by the introduction of methamphetamine and cocaine into the equation. Unlike opioids and fentanyl, cocaine and amphetamines are stimulants and, according to recent research, nearly 50% of overdose deaths since 2022 have involved stimulants. In many of the reported cases, stimulants were present in combination with opioids; however, stimulants alone were the cause of overdose in an increasing number of cases.
This new trend is worrisome, not only because it signifies a changing illegal drug landscape but also because there is no evidence-based treatment available for people struggling with stimulant use disorder. In response to the first three waves of the opioid crisis, many management strategies and treatment options now exist for those struggling with opioid use; unfortunately, the same cannot be said for stimulant users. [4]
What Can We Do?
The absence of proven methods for coping with this fourth wave of overdose crisis in the US, combined with the changing landscape of drug use, has made working in substance use disorder treatment challenging at times. However, many psychiatrists and drug researchers have suggested that a practice known as contingency management, or CM, is a useful intervention for treating stimulant-based substance use disorder in clients.
Contingency management involves an emphasis on reward as a form of behavioral therapy, where positive behavioral change is reinforced. This has been demonstrated to have particular efficacy in dealing with stimulant use cases. For instance, one study showed that the percentage of individuals who sustained stimulant abstinence over 12 weeks was nearly 4 times greater when contingency management was used, as compared to standard care.[5]
Regardless of how we approach it, recognizing changes in the nature of drug use and abuse and what they mean for the prevalence of overdose in the United States is critical when we provide treatment to those affected by harmful opioids and stimulants.
If you or anyone you know is struggling with substance use, please reach out. Our team of highly trained professionals is here to help support you through your treatment journey.
Sources:
[1] https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2024/20240515.htm
[2] Mann, B. (2021) ‘More than a million Americans have died from overdoses during the opiod epidemic. NPR. December 30. https://www.npr.org/2021/12/30/1069062738/more-than-a-million-americans-have-died-from-overdoses-during-the-opioid-epidemi
[3] Feldscher, K. (2022) ‘What led to the opioid crisis—and how to fix it?’ Harvard.edu. February 9. https://www.hsph.harvard.edu/news/features/what-led-to-the-opioid-crisis-and-how-to-fix-it/
[4] Rawson, R.A. et al. (2023) ‘The fourth wave of the overdose crisis: Examining the prominent role of psychomotor stimulants with and without fentanyl.’ Preventative Medicine. V 176. https://doi.org/10.1016/j.ypmed.2023.107625
[5] Petry NM. (2011) Contingency management: what it is and why psychiatrists should want to use it. Psychiatrist. May;35(5):161-163. doi: 10.1192/pb.bp.110.031831.
