Charting the decline of the fourth wave: US overdose deaths by race, ethnicity and substance involvement.
Level 3 - non-randomized controlled study
Population-based longitudinal vital statistics analysis (graded by design analogy)
PubMed 42227062 · doi:10.1111/add.70472
What was done
Population-based epidemiological study analyzing national death records from the CDC WONDER database between January 1999 and December 2024 using an underlying cause of death approach. The authors evaluated annual drug overdose mortality rates per 100,000 population, examining changes between 2023 and 2024 stratified by race/ethnicity and specific substance involvement (fentanyl, stimulants, and xylazine).
What was found
The overall US drug overdose mortality rate decreased 24.4% between 2023 and 2024 to 23.7 per 100,000, marking the first decline in the "fourth wave" (fentanyl co-involved with stimulants). Reductions were driven by declining fentanyl-involved deaths, whereas xylazine-involved deaths and deaths involving stimulants without fentanyl grew as a proportion of total fatalities. Non-Hispanic Black individuals saw a 29.3% drop to 36.0 per 100,000 (1.51 times the national average). Non-Hispanic American Indian and Alaska Native individuals had a 20.1% drop but retained the highest overdose death rate in 2024 at 50.8 per 100,000 (2.15 times the national average).
Why it matters
This documents the first national downturn in fentanyl-and-stimulant co-involved overdose deaths after years of increases, while identifying persistent racial disparities and the emerging proportional footprint of xylazine and non-fentanyl stimulant fatalities.
Limits
Relying on CDC WONDER death certificate records introduces potential misclassification due to variations in local coroner/medical examiner reporting, toxicology testing practices, and delays in cause-of-death certification. Total decedent count (n) was not specified in the abstract.
Cited by
- supports 100,000 people died of drug overdoses in the last year.