In early 2020, the opioid overdose crisis in the U.S. entered a fourth phase, which research scientists think may be the most dangerous phase of the crisis yet.
If you’re not familiar with how the opioid crisis unfolded over time, it’s important to understand the crisis is now in its third decade.
That may come as a shock to many people, who likely first heard about the opioid crisis between 2015 and 2017, a period that began when leaders at the state level – in Ohio and California, for instance – began implementing policies to reduce the harm caused by opioid addiction and overdose, and ended when former President Trump announced a nationwide strategy that followed the template created by local and state leaders.
The first phase of the crisis began in the late 1990s. This phase was the result of massive overprescribing of opioid pain medication, which led to a drastic increase in opioid use disorder (OUD) – a.k.a. opioid addiction – and opioid overdose, nationwide.
The second phase began around 2007 and was driven by the prescription to addiction pathway. Many people developed OUD when using prescription opioids. Then, when prescribing practices changed, reducing access to prescription opioids, many people turned to illicit sources of opioids, including heroin, which led to another spike in opioid overdose.
The third phase, which began around 2013, was driven by an influx of illicit fentanyl and other synthetic opioids. Fentanyl is 50 times stronger than heroin and 100 times stronger than morphine, and this extreme potency cause misuse and overdose to spike again, nationwide.
The fourth phase – driven by the presence of fentanyl in non-opioid drugs of misuse and exacerbated by the COVID-19 pandemic – began around 2019 and continues to escalate as we write this article.
Phase Four: Increased Risk in Rural Areas
A paper published in July 2022 called “Geographic Trends in Opioid Overdoses in the US From 1999 to 2020” uses twenty-one years of data on the opioid crisis to predict – and warn the general public – the direction the fourth phase of the crisis is likely to take.
The research team defines the goal of their work as follows:
“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.”
To that end, they took a unique perspective: they examined the crisis using geographic criteria. While most studies on the crisis focus on rates of OUD, rates of fatal and nonfatal overdose, and the results of various treatment and preventions strategies, this study focused on comparing overdose rates between urban and rural areas. The goal – as implied by the statement “to inform prevention and mitigation strategies” is to help policymakers at the local, state, and federal level anticipate where the greatest level of need will be in the upcoming months and years.
The adage preparation is prevention applies here. If we understand where the next spike in OUD and opioid overdose might occur, we can allocate resources to offer support in those specific areas before the spikes appear – and we may be able to reduce their magnitude and impact.
The Geography of the Opioid Crisis
Let’s look at how the three waves opioid crisis occurred, with respect to geography, as determined by the research team after analyzing two decades of publicly available data published by the Centers for Disease Control (CDC) in the WONDER Database.
Researchers divided data into four categories:
- Large central metro: Urban areas with over 1,000,000 residents
- Large fringe metro: Suburbs of large central metro areas
- Medium metro: Midsize cities with 250,000-999,999 residents
- Small metro: Towns in rural areas with fewer than 250,000 residents
- Micropolitan: Areas close to towns considered small metro
- Noncore: Rural areas unrelated to any metro area
Within this system and these categories, large central metro corresponds to the most urban areas, while noncore corresponds to the most rural areas.
Here’s what they found:
First Phase, Late 90s – 2007
- In this phase, noncore and large central metro areas showed the highest rates of opioid overdose (OOD)
- Rates of OOD increased most rapidly in noncore and micropolitan areas
Second Phase, 2007 – 2013
- In this phase, all areas – urban and rural – showed parallel and similar linear increases in OOD
- OOD in noncore areas was highest – and higher than all other areas – around 2010
- OOD rates in noncore areas declined from 2010-2012, but increased again beginning in late 2012
- Rates of OOD in large fringe metro areas – i.e. the suburbs of big cities – were higher than all other areas in 2011-2012, but increased again in late 2012
Third Phase, 2013 – 2019
- In this phase, OOD rates in noncore areas remained relatively stable
- Between 2016-2017, OOD rates in large central metro and large fringe metro areas were higher than all other areas.
- OOD rates in all areas dropped between late 2017 and early 2018, but began to increase again in late 2019 and early 2020
Fourth Phase, 2019 – Present
The two years of available data for this current phase indicate that rates of OOD are increasing across all geographic areas, with the greatest acceleration of OOD rates in noncore areas, followed by medium metro, small metro, and micropolitan areas. Areas classified as large fringe metro – as of 2020 – showed the slowest increases in this phase of the crisis.
How This Research Helps
The years 2019-2021 have been devastating.
We’re not talking about the pandemic or the contentious politics.
We’re talking about overdose deaths. Between 1999 and 2019, overdose deaths increased by around 300 percent. That’s an increase of about 15 percent per year. Between 2019 and 2021, overdose deaths increased by about 60 percent, which is about 20 percent per year.
That means that over the past three years, we’ve seen a dramatic increase in overdose deaths – and that dramatic increase began from a baseline 300 percent higher than the pre-crisis numbers reported in 1999.
The crisis is escalating.
This research tells us that we need to target our prevention and treatment efforts in rural areas – noncore areas, according to the classification system in the study we discuss – and that we need to target those prevention and treatment effort to the population in most need.
Here’s how Dr. Lori Post of Northwestern University, a lead author on the study interviewed in the online magazine Science Daily, views the data:
“I’m sounding the alarm because, for the first time, there is a convergence and escalation of acceleration rates for every type of rural and urban county. Not only is the death rate from an opioid at an all-time high, but the acceleration of that death rate signals explosive exponential growth that is even larger than an already historic high.”
We’ll be honest: that quote is alarming. It’s not nearly as alarming as what Dr. Post said in an interview published by Northwestern Now:
“We have the highest escalation rate for the first time in America, and this fourth wave will be worse than it’s ever been before. It’s going to mean mass death.”
We don’t spook easily – but that has us close. However, we’re committed and ready – and we know we can make a difference.
In both rural and urban areas, making a difference means increasing access to care, increasing harm reduction programs such as mobile medication-assisted treatment (MAT) units, needle exchange programs, Narcan training and distribution programs, and MAT programs in rural community clinics and health centers. Evidence shows harm reduction strategies can reduce rated of relapse, overdose, and death related to opioid use and misuse. If we follow the data and expand our level of commitment and support for the people with OUD in rural and urban areas, we can save lives in the years to come.