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Opioid-Related Mortality – 3 Waves

Chaim Miller, BA

Asif Ilyas, MD, MBA, FACS

Takeaway Points:

  • The CDC categorized the past 20 years of drug overdose data into 3 waves to better portray the changing problems that need addressing in the opioid epidemic.

  • The first wave was defined by a sharp increase in prescription opioid deaths following a period of over treating pain.

  • The second wave was defined by a prevalence in readily available and cheaper heroin, leading to a significant increase in heroin overdose mortality.

  • The third wave was categorized by an increase in synthetic opioids, such as Fentanyl, which is often used in combination with other drugs, such as heroin and cocaine.

  • Looking at the overdose data in a more detailed view provides legislators the ability to effectively address the changing problems we face in America.


Understanding the drug overdose trends over the past 20 years is key to an effective strategy in combating the opioid epidemic in America. From 1999 until 2017, the U.S. saw a 5-fold increase in opioid overdose deaths, with 2018 being the only year in which total drug deaths declined nationally.1 This recent change is already reversing as the Coronavirus pandemic has impacted the lives of those already struggling with a drug use disorder.2 Universally, opioids have been the highest contributing drug towards overdose deaths, sometimes reaching 4 times higher than its closest competitor (cocaine). However, the current situation regarding opioid abuse has not been consistent since 1999. In fact, the CDC has categorized the 20 years from 1990 to 2018 into 3 specific waves, which will be analyzed below (Image 1).

  1. Early 90’s to 2009

The CDC states this period was defined by an increase in prescription opioids (natural and semi-synthetic opioids) most probably due to an overcorrection of medical professionals after a period of “opiophobia” in the 1980’s. By this time, the American Pain association and other groups developed protocols for the treatment of acute and chronic pain with opioids on the back of flawed data which implied little abuse potential for opioids received in the hospital.3 During this time, over-prescribing of opioids was overtly encouraged, as hospitals receive federal reimbursements based on how they performed relative to patient’s pain control.4 In this period, prescription opioid deaths increased from 3,442 in 1999 to 13,523 in 2009, an almost 3 fold increase.

  1. 2010-2012

According to the CDC, this wave was significant for the rapid rise in heroin-related deaths. During this time, drug deaths due to heroin rose from 3,036 in 2010 to 5,925 in 2012, a nearly 100% increase. The demographical data portrayed these new users as those who had originally been introduced to opioids by their prescription (such as Oxycontin) and found heroin to be a cheaper and more accessible option.5 Deaths related to prescription opioids also remained high during this period.6 This period remains a notable public hazard as this signified the rise of injectable drugs, which is associated with other intravenous-related comorbidities.

  1. 2013- 2018

The third wave is characterized by an increase in deaths related to synthetic opioids, such as Fentanyl. During this time, overdose deaths due to Fentanyl increased over 9 fold, from 3,105 in 2013 to 31,335 in 2018. Fentanyl is also commonly used to “spike” other drugs, as it is seen as a cheaper option for those manufacturing it illegally. Some states have found that almost half of the overdose deaths involving fentanyl also test positive for heroin and cocaine.7,8

  1. Demographical Data of Drug Overdose Trends

Paralleling the increase in illegally manufactured Fentanyl, overdose rates in minority communities, including Blacks and Hispanics, have increased steadily even with a low rate of overdose deaths historically. In a study conducted between 2015-2017, nearly all racial/ethnic groups and age groups experienced increases in opioid-involved and synthetic opioid–involved overdose death rates. This particularly affected blacks in large central metropolitan areas, and non-Hispanic white in large fringe metro areas.9 However, since the early 2000s, Non-Hispanic Whites have had the largest age-adjusted opioid-related death rate per 100,000 population followed closely by Blacks. Asian and Pacific Islanders have had the lowest age-adjusted rate per 100,000 population consistently since 1999. Until 2005, the 35-44 age group held the highest number of overdose deaths, after which the 45- 54 age group held the highest number until 2014. More recently, in 2017, the 25 to 34 age group has the highest number of overdose deaths.10

Image 1: Trends in drug overdose data. Three data points reveal the three waves designated by the CDC to have been a significant turning point in the makeup of drug overdoses nationally.


  1. National Center on Health Statistics, CDC WONDER

  2. Katz, Josh, et al. “In Shadow of Pandemic, U.S. Drug Overdose Deaths Resurge to Record.” The New York Times, The New York Times, 15 July 2020,

  3. Bernard SA, Chelminski PR, Ives TJ, Ranapurwala SI. Management of Pain in the United States-A Brief History and Implications for the Opioid Epidemic. Health Serv Insights. 2018;11:1178632918819440. Published 2018 Dec 26. doi:10.1177/1178632918819440

  4. Anne Rossier Markus and Sara Rosenbaum. (2006, October 01). The Deficit Reduction Act of 2005: An Overview of Key Medicaid Provisions and Their Implications for Early Childhood Development Services. Retrieved October 19, 2020, from

  5. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014 Jul 1;71(7):821-6. doi: 10.1001/jamapsychiatry.2014.366. PMID: 24871348.

  6. Seth P, Rudd RA, Noonan RK, Haegerich TM. Quantifying the Epidemic of Prescription Opioid Overdose Deaths. Am J Public Health. 2018 Apr;108(4):500-502. doi: 10.2105/AJPH.2017.304265. PMID: 29513577; PMCID: PMC5844400.

  7. O’Donnell JK, Gladden RM, Seth P. Trends in deaths involving heroin and synthetic opioids excluding methadone, and law enforcement drug product reports, by census region—United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017;66:897–903.

  8. Drug Enforcement Administration. 2017 national drug threat assessment summary. Washington, DC: US Department of Justice, Drug Enforcement Administration; 2017.

  9. Mack KA, Jones CM, Ballesteros MF. Illicit drug use, illicit drug use disorders, and drug overdose deaths in metropolitan and nonmetropolitan areas—United States. MMWR Surveill Summ 2017;66(No. SS-19).

Kaiser Family Foundation analysis of Centers for Disease Control and Prevention (CDC), National Center for Health Statistics. Multiple Cause of Death 1999-2018 on CDC WONDER Online Database, released 2020. Data are from the Multiple Cause of Death Files, 1999-2018, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at on October 10th, 2020.

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