Citation

Post LA, Lundberg A, Moss CB, Brandt CA, Quan I, Han L, Mason M. JAMA Netw. Open 2022; 5(7): e2223631.

Copyright

(Copyright © 2022, American Medical Association)

DOI

10.1001/jamanetworkopen.2022.23631

PMID

unavailable

Abstract

The US opioid crisis has evolved over time. Ciccarone1 posited a theory of 3 overlapping waves of opioid-involved overdose deaths (OODs) based on supply (iatrogenic and new illicit sources) and demand (social, cultural, and technological). Wave 1, in approximately 2000, was prompted by doctors overprescribing opioid painkillers, which was associated with mass addiction.1 Wave 2 involved heroin; OODs from heroin escalated in 2007 and surpassed those from prescription opioids by 2015.1 Wave 3 involved illicit synthetic opioids, such as fentanyl, the use of which escalated after 2013.1 Further evidence suggests a fourth wave, complicated by the addition of stimulants and the COVID-19 pandemic.2 To inform prevention and mitigation strategies, this cross-sectional study examined trends in OOD rates in urban and rural US counties during the 4 waves...

... Overall, OOD rates increased steadily in counties of every urbanicity type, although there were distinct temporal wave patterns by urbanicity. Before 2010, OOD rates accelerated more quickly in rural counties than in urban counties; before 2000, OODs were rare in rural communities, which lacked resources to treat opioid use disorders associated with prescription opioids in wave 1.3

Restrictions on synthetic and semisynthetic opioids are associated with increased heroin use, which contributed to wave 2.4 OOD rates accelerated more quickly in urban counties during wave 2, beginning approximately in 2013.

From 2013 to 2019, OODs from fentanyl increased 12-fold. This third wave substantially impacted urban and rural counties. The COVID-19 pandemic coincided with a fourth wave marked by worsening of the opioid crisis in all county types...