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Review
. 2021 Jul 1;34(4):344-350.
doi: 10.1097/YCO.0000000000000717.

The rise of illicit fentanyls, stimulants and the fourth wave of the opioid overdose crisis

Daniel Ciccarone  1
Affiliations
Review

The rise of illicit fentanyls, stimulants and the fourth wave of the opioid overdose crisis

Daniel Ciccarone. Curr Opin Psychiatry. .

Abstract

Purpose of review: This review provides an update on recently published literature on the rise of illicit fentanyls, risks for overdose, combinations with other substances, e.g. stimulants, consequences, and treatment.

Recent findings: Overdose due to illicit synthetic opioids (e.g. fentanyl and fentanyl analogs) continues to rise in the US both preceding and during the COVID-19 pandemic. Fentanyl-related overdose is rising in new geographic areas e.g. the western USA. Stimulant-related overdose is also increasing nationwide driven by methamphetamine and cocaine. Polysubstance use, e.g. the use of a stimulant along with an opioid is driving stimulant-related overdose. Other medical consequences of injection drug use are rising including HIV and hepatitis C infections. Medication approaches to treating opioid use disorder remain the standard of care and there are new promising pharmacological approaches to treating methamphetamine use disorder.

Summary: A 'fourth wave' of high mortality involving methamphetamine and cocaine use has been gathering force in the USA. Availability and use of illicit fentanyls are still the major drivers of overdose deaths and the current rise in stimulant-related deaths appears entwined with the ongoing opioid epidemic.

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Conflict of interest statement

Conflicts of interest:

Dr. Ciccarone has received compensation in the past 36 months for: being on the Scientific Advisory Board for Celero Systems; providing expert testimony for Motley Rice LLP; being a one-time consultant for Mallinckrodt Pharmaceuticals; and being a one-time consultant for Nektar Therapeutics; all outside the submitted work.

References

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      The most recent official report on US mortality from the National Center for Health Statistics, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.

    1. Ciccarone D, The triple wave epidemic: supply and demand drivers of the US opioido verdose crisis. Int J Drug Policy, 2019. 71: p. 183–188.

      ** This paper describes the epidemiological pattern of three intertwined waves of mortality from three sub-classes of opioids: natural and semi-synthetics (e.g. prescription opioid medications), heroin, and synthetic opioids, other than methadone (i.e. fentanyl, fentanyl analogs and others). It crucially summarizes the main supply and demand drivers of each wave along with the implications for public policy.

    1. Ciccarone D, Fentanyl in the US heroin supply: A rapidly changing risk environment. International Journal of Drug Policy, 2017. 46: p. 107–111. - PMC - PubMed

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      * Highlights the geographic distribution and demographics of drug overdose in the US utilizing the latest official data (2018) from the US Centers for Disease Control and Prevention.

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