Charting the Decline of the Fourth Wave: US Overdose Deaths by Race, Ethnicity, and Substance Involvement

To characterize decreases in overdose death rates in the United States between 2023 and 2024 by race/ethnicity, and substance involvement.

Population-based study of national death records accessed via the Centers for Disease Control and Prevention (CDC) Wide-ranging ONline Data for Epidemiologic Research (WONDER) platform using an underlying cause of death approach.

United States (US).

All individuals who died from drug overdose between January 1999 and December 2024.

Annual overdose deaths per 100,000 population. Year of occurrence of overdose death; substance involvement; race/ethnicity of decedents.

After many years of increases, the US overdose death rate dropped 24.4% between 2023 and 2024. Decreases reflected declining illicit fentanyl-involved deaths (with and without stimulant involvement). The fourth wave of the US overdose crisis-defined by deaths involving fentanyl together with stimulants-declined for the first time in 2024. Despite overall decreases, deaths involving stimulants without fentanyl, and xylazine, continued to represent a growing fraction of overdose fatalities. Non-Hispanic Black and African Americans had the largest decrease in death rates in 2023-2024-falling 29.3%, but remained elevated at 36.0 per 100,000, 1.51 times higher than the national average of 23.7 per 100,000. Non-Hispanic American Indian and Alaska Native individuals had the highest overdose death rates rate in 2024, at 50.8 per 100,000, representing 2.15 times the national average rate, and experienced a below-average relative decrease of 20.1%.

All four previously defined waves of the US overdose crisis are in decline, as deaths involving illicit fentanyl, with and without stimulants, are dropping sharply. Concurrently, the fraction of overdose deaths involving stimulants without fentanyl and those involving xylazine, continued to increase. While racial disparities in drug overdose death rates narrowed slightly during this period, significant gaps remain, with the highest rates among American Indian, Alaska Native, and Black individuals.