Charting the decline of the fourth wave: US overdose deaths by race, ethnicity and substance involvement
5 affiliations
- 1Department of Psychiatry University of California San Diego CA USA
- 2Department of Population Health NYU Grossman School of Medicine New York NY USA
- 3Department of Family Community Medicine University of California San Francisco CA USA
- 4Department of Medicine University of California San Diego CA USA
- 5Department of Medicine University of California Los Angeles Los Angeles CA USA
Abstract
AIMS: To characterize decreases in overdose death rates in the United States (US) between 2023 and 2024 by race/ethnicity, and substance involvement. DESIGN: Population-based study of national death records accessed via the Centers for Disease Control and Prevention (CDC) Wide-ranging ONline Data for Epidemiologic Research (WONDER) platform using an underlying cause of death approach. SETTING: US. PARTICIPANTS/CASES: All individuals who died from drug overdose between January 1999 and December 2024. MEASUREMENTS: Annual overdose deaths per 100 000 population. Year of occurrence of overdose death, substance involvement, race/ethnicity of decedents. FINDINGS: After many years of increases, the US overdose death rate dropped 24.4% between 2023 and 2024. Decreases reflected declining illicit fentanyl-involved deaths (with and without stimulant involvement). The fourth wave of the US overdose crisis-defined by deaths involving fentanyl together with stimulants-declined for the first time in 2024. Despite overall decreases, deaths involving stimulants without fentanyl and deaths involving xylazine continued to represent a growing fraction of overdose fatalities. Non-Hispanic Black and African Americans had the largest decrease in death rates in 2023-2024, falling by 29.3% but remaining elevated at 36.0 per 100 000, 1.51 times higher than the national average of 23.7 per 100 000. Non-Hispanic American Indian and Alaska Native individuals had the highest overdose death rates rate in 2024, at 50.8 per 100 000, 2.15 times the national average rate, and experienced a below-average relative decrease of 20.1%. CONCLUSIONS: All four previously defined waves of the US overdose crisis appear to be in decline, as deaths involving illicit fentanyl, with and without stimulants, dropped sharply between 2023 and 2024. Concurrently, the fraction of overdose deaths involving stimulants without fentanyl and those involving xylazine continued to increase. While racial disparities in drug overdose death rates narrowed slightly during this period, large gaps remain, with the highest overdose death rates among American Indian, Alaska Native, and Black individuals.
Related
- Responding to the increase in substance use, HIV, HCV, and overdose in New England (RISE-NE): Protocol for a prospective cohort study
- Sex differences in depression and substance use disorder diagnoses and overdose risk in British Columbia
- Reporting of Race, Ethnicity, Sexual and Gender Minority Identity, and Youth Involvement in Evidence for Youth-Facing AI Mental Health Tools: Scoping Review
- Substance dependence: distinct transcriptomic patterns and neuroimmune system involvement in addiction pathogenesis and progression
- Brain AT₁ Receptor Involvement in Cognitive Decline and Neuroinflammation in Streptozotocin-Treated Rats
BibTeX
@article{friedman2026charting,
title = {{Charting the decline of the fourth wave: US overdose deaths by race, ethnicity and substance involvement}},
author = {Joseph R. Friedman and Joseph J. Palamar and Daniel Ciccarone and Tommi Gaines and Annick Bórquez and Chelsea L. Shover and Steffanie A. Strathdee},
journal = {Addiction},
year = {2026},
month = jun,
doi = {10.1111/add.70472},
url = {https://doi.org/10.1111/add.70472},
note = {CC BY-NC-ND},
}
RIS
TY - JOUR
TI - Charting the decline of the fourth wave: US overdose deaths by race, ethnicity and substance involvement
AU - Joseph R. Friedman
AU - Joseph J. Palamar
AU - Daniel Ciccarone
AU - Tommi Gaines
AU - Annick Bórquez
AU - Chelsea L. Shover
AU - Steffanie A. Strathdee
PY - 2026
DA - 2026/06/02
JO - Addiction
DO - 10.1111/add.70472
UR - https://doi.org/10.1111/add.70472
AB - AIMS: To characterize decreases in overdose death rates in the United States (US) between 2023 and 2024 by race/ethnicity, and substance involvement. DESIGN: Population-based study of national death records accessed via the Centers for Disease Control and Prevention (CDC) Wide-ranging ONline Data for Epidemiologic Research (WONDER) platform using an underlying cause of death approach. SETTING: US. PARTICIPANTS/CASES: All individuals who died from drug overdose between January 1999 and December 2024. MEASUREMENTS: Annual overdose deaths per 100 000 population. Year of occurrence of overdose death, substance involvement, race/ethnicity of decedents. FINDINGS: After many years of increases, the US overdose death rate dropped 24.4% between 2023 and 2024. Decreases reflected declining illicit fentanyl-involved deaths (with and without stimulant involvement). The fourth wave of the US overdose crisis-defined by deaths involving fentanyl together with stimulants-declined for the first time in 2024. Despite overall decreases, deaths involving stimulants without fentanyl and deaths involving xylazine continued to represent a growing fraction of overdose fatalities. Non-Hispanic Black and African Americans had the largest decrease in death rates in 2023-2024, falling by 29.3% but remaining elevated at 36.0 per 100 000, 1.51 times higher than the national average of 23.7 per 100 000. Non-Hispanic American Indian and Alaska Native individuals had the highest overdose death rates rate in 2024, at 50.8 per 100 000, 2.15 times the national average rate, and experienced a below-average relative decrease of 20.1%. CONCLUSIONS: All four previously defined waves of the US overdose crisis appear to be in decline, as deaths involving illicit fentanyl, with and without stimulants, dropped sharply between 2023 and 2024. Concurrently, the fraction of overdose deaths involving stimulants without fentanyl and those involving xylazine continued to increase. While racial disparities in drug overdose death rates narrowed slightly during this period, large gaps remain, with the highest overdose death rates among American Indian, Alaska Native, and Black individuals.
SN - 0965-2140
SN - 1360-0443
ER -