The Changing Demographics of the Opioid Epidemic

Introduction

Since the first wave of the opioid epidemic in the 1990s, more than 550,000 people from various backgrounds have died of an overdose in the United States.¹ In 2023, opioid overdose deaths decreased 3% nationwide and by 10% in states like New York—the first decline in the last decade.² Furthermore, the Centers for Disease Control and Prevention (CDC) recently reported a near 24% decline in overdose deaths between October 2023 and September 2024 compared to the previous year.³ While these milestones may bring hope to communities across the country, community leaders are also reporting alarming racial and ethnic disparities in these health trends. Emergency departments (EDs) are at the frontlines of the opioid epidemic, treating individuals who are in acute withdrawal or postoverdose.⁴ Therefore, emergency physicians and ED staff members must be aware of the changing demographics of the opioid epidemic and the resources available to effectively address opioid use disorder (OUD).

The Waves of the Opioid Epidemic

The distinct waves of the opioid epidemic presented unique challenges in communities across the United States, necessitating rapid and adaptive responses from public, private, and nonprofit sectors to address the evolving patterns of substance use, shifting demographics, and emerging public health threats. Table 1 summarizes the four waves of the opioid epidemic.^5-9,15,17

The First Wave

The first wave of the opioid epidemic was marked by a drastic rise in opioid prescribing and overdose deaths across the United States in the 1990s.⁹ Many experts believe that this surge was driven by marketing strategies from pharmaceutical companies promoting aggressive prescribing for opioids, such as OxyContin.^10,11 This, coupled with insufficient oversight and regulatory shortcomings by governmental agencies, including the US Food and Drug Administration, permitted the dissemination of misleading information about the safety and efficacy of these drugs.^10,11

During this first wave, non-Hispanic Whites aged 45-54 had the highest opioid overdose mortality rates.¹² This health disparity can be associated with inequitable access to health care and medications for addiction treatment (MAT) among different racial and ethnic groups, as well as older adults seeking medical care more frequently than younger populations.^13,14 Once efforts were made to control over-prescribing of opioids, many individuals sought illicit substances to manage cravings and withdrawal symptoms. This uptick in illicit opioid use, specifically heroin, led to a second wave of the opioid epidemic by 2010.⁹

The Second Wave

The second wave of the opioid epidemic was marked by increased overdoses in non-Hispanic Black individuals ages 45-64.¹⁵ This age group was most impacted for a variety of reasons; as regulations around opioid-prescribing tightened, access to legally obtained opioids decreased. Many people with OUD transitioned to using illicit opioids to manage cravings and withdrawal symptoms.¹⁶ Between 2000 and 2013, the number of heroin-involved overdoses nearly quadrupled.¹⁷ Between 2010 and 2016, heroin-involved deaths increased from 1% to 4.9% per 100,000.⁹ Although there have been many changes in the age of those who are most affected by the opioid epidemic, the shift in race-based demographics has remained consistent.

The Third Wave

In 2013, the third wave of the opioid epidemic emerged and was characterized by overdose deaths involving synthetic opioids, particularly fentanyl.¹⁸ Non-Hispanic Black communities were disproportionally impacted, with the rate of fentanyl overdose deaths increasing among non-Hispanic Black people by about 140% every year between 2011 and 2016.¹² Unlike the first and second waves, two distinct age groups experienced the most dramatic increase in opioid-involved overdose deaths during the third wave of the opioid epidemic: opioid overdose death rates increasing by 4.6 per 100,000 for men aged 25-44 and 3.7 per 100,000 for men aged 45-64.¹⁹ One potential reason for this shift in age may be that younger people are more likely to misuse illicit substances compared to older adults.²⁰ Older adults are more likely to receive prescription medications like opioids compared to younger people and, therefore, are less likely to seek illicit substances from other sources.²¹ Figure 1 displays the different waves of the opioid epidemic (as defined by the CDC) and the demographics of those who were most impacted by each wave.^5,22-24

The Fourth Wave

Although national leaders like the CDC recognize only three waves of the opioid crisis, many academic journals have published literature on a fourth wave of the epidemic.^18,25-27 This fourth, and current, wave is characterized by increased rates of opioid overdose deaths with involvement of stimulants.^26,27 This presents a distinct challenge across communities in the United States because many people who use stimulants are not seeking opioids and may not have a tolerance. Fentanyl is the primary driver of all opioid overdose deaths in the United States; because of its shorter period of euphoria compared to heroin, sedatives like xylazine and medetomidine are being added to the illicit fentanyl supply to lengthen its effects.^28,29 These sedatives do not respond to naloxone and have effects including hypotension and respiratory depression, further complicating overdose response and prevention strategies.

The disparity in overdose rates among different racial and ethnic populations is particularly evident when looking at the third (and fourth) wave(s) of the opioid epidemic. In May 2024, the CDC announced the first decline in opioid overdose deaths nationwide since 2018, but there were alarming racial disparities in these health outcomes.^3,30,31 Notably, opioid overdose deaths decreased among White people by 14%, but decreased by only 6% for Black communities and 2% for Asian or Pacific Islanders. Overdose deaths also increased for Native American/American Indian populations by 2%.^30,31 These changes in the demographics of people most impacted by the opioid epidemic call for action at the local, state, and federal levels to address racial bias and health care discrimination.

Emergency Medicine Breeds Innovation

Being that EDs are often the first point of interaction with healthcare services for most people with OUD, emergency medicine physicians and staff members are critical stakeholders in addressing the opioid overdose epidemic across the United States.⁴ Recent shifts in overdose death rates across races demonstrate the systemic issues in the U.S. healthcare system, including health inequities, discrimination, and implicit bias. To begin addressing these health inequities, EDs must employ various interventions for OUD to meet patients where they are; these interventions should include initiation of MAT, linkage to outpatient treatment, and distribution of harm reduction supplies.⁴

Medication for Addiction Treatment and Electronic Referrals (MATTERS) is a New York-based initiative that, since its inception in 2016, has supported EDs in linking people with OUD to treatment and resources within their own communities. Its rapid referral platform connects people with OUD to a network of over 250 addiction treatment centers that offer MAT and agree to accept any patient, regardless of insurance status, polysubstance use, or previous treatment history. Developed by Joshua Lynch, an emergency physician, MATTERS was created to address the inefficiencies in the way our healthcare system addressed OUD. Referrals take as little as 3 minutes to complete, and patients are automatically provided with medication and transportation vouchers, peer support referrals, and follow-up services to ensure continuity of care and retention in treatment. These resources are automatically provided to patients at the time of referral—all without making a single phone call. For individuals who are not ready for treatment, MATTERS distributes free harm reduction supplies, including drug checking strips, naloxone, and sterile syringes via direct mail. Additionally, MATTERS has deployed over 20 vending machines across New York State to dispense these free supplies 24/7.

Conclusion

While each wave of the opioid epidemic has affected communities differently, the third and fourth waves have revealed and intensified health disparities, particularly among Black, Indigenous, and people of color (BIPOC) communities.³² To effectively reduce overdose rates and address opioid use disorder, it is essential for emergency physicians and ED staff members to prioritize equitable, inclusive, and culturally competent prevention and treatment strategies.⁴ MATTERS provide various services to patients and providers alike to effectively respond to the opioid epidemic, including linkage to treatment, access to telemedicine services, and distribution of free harm reduction supplies across New York State. Providers seeking resources for OUD can access educational materials and support by visiting www.mattersnetwork.org.

Correction

In the April issue (EMN. 2025;47(3):2,11,15), the 2nd sentence of the 11th paragraph of the article, “STEMI Critics Are Right. We're Missing Too Many Heart Attacks,” has been changed to Why did we need that? (How do I pronounce that again?)—the case for the new OMI/non-occlusive myocardial infarction (NOMI) paradigm is powerful. This change has been made online.

JOSHUA LYNCH, DO, FACEP is the founder and Chief Medical Officer of the MATTERS program. He is also an associate professor of Emergency & Addiction Medicine at the University at Buffalo Jacobs School of Medicine, a senior physician with UBMD Emergency Medicine, clinical co-chair of the UB Clinical & Research Institute on Addictions, and medical director of Mercy Flight of Western New York.

LUCY CONNERY, MPH is the marketing coordinator at MATTERS. She also serves as an adjunct professor for Daemen University's Health Promotion and Master of Public Health departments and secretary of the Urban Roots Cooperative Garden Market's Board of Directors.

KAILYN TOMILIN, MPH is the program evaluator at MATTERS and has written several evidence-based articles on emerging drug threats and contaminants in the United States. She has a passion for public health and plans to spend her career helping to improve health outcomes for underserved populations.

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