Medicines

by Connery, Lucy MPH; Tomilin, Kailyn MPH; Lynch, Joshua DO, FACEP – Emergency Medicine News

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.

Table 1 – Summary of demographics, data, and trends of the opioid epidemic

Wave	Time Period	Primary Driver	Most Impacted Demographics	Data Trends & Consequences
First wave	1990-2010	Increased opioid prescribing, aggressive pharmaceutical marketing, and regulatory shortcomings from federal agencies	Non-Hispanic White individuals, ages 45-54	1999-2009: Prescription opioid overdose deaths rose from ~3,442 to 13,523
Second wave	2010-2013	Opioid-prescribing regulations tightened, shift from prescription opioids to heroin due to cost and accessibility	Non-Hispanic Black individuals, ages 45-64	2000-2013: Heroin-related overdoses nearly quadrupled 2010-2016: Heroin-involved deaths increased from 1% per 100,000 to 4.9% per 100,000
Third wave	2013-2019	Proliferation of synthetic opioids, particularly fentanyl	Younger individuals (ages 25-34) and non-Hispanic Black populations (ages 45-64)	2012-2016: Drug overdose deaths rose from 1,600 to over 18,000 nationwide 2013-2019: Opioid overdose rates from synthetic opioids (particularly fentanyl) increased over 1,000%
Fourth wave	2019-present	Increasing presence of fentanyl mixed with stimulants (eg, cocaine, methamphetamine) and other contaminants (eg, xylazine)	Non-Hispanic Black, Hispanic, and Indigenous populations	2018: Synthetic opioid overdose rates increased 79% for White individuals and over 100% for Black individuals 2018-2022: EMS agencies’ nonfatal opioid overdose encounters increased 3.4% for White, 7.4% for Black, and 5.7% for Hispanic people

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.

Source: https://journals.lww.com/em-news/fulltext/2025/05000/the_changing_demographics_of_the_opioid_epidemic.10.aspx

Filed under: Latest News,Medicines,Opioids,Prevalence,USA :

by Mark Gold M.D. – Professor of Psychiatry, Yale, Florida and Washington Universities

Updated February 27, 2025 | Reviewed by Gary Drevitch

Key points

Teen nonmedical misuse of medications may be more common than previously reported.
Adolescents misuse dextromethorphan (DXM) products for their dissociative/hallucinogenic effects and euphoria.
A recent alert highlights increasing adolescent interest in using DXM and promethazine together

According to Sharon Levy, MD,Harvard Medical School’s pediatric addiction expert, nonmedical medication misuse may be much more common than previously reported. One of the older fads is in the news again: getting high from cough and cold medicines containing dextromethorphan (DXM). This drug is sometimes combined with prescribed promethazine with codeine. At very high doses, DXM mimics the effects of illegal drugs like phencyclidine (PCP) and ketamine.

More than 125 over-the-counter (OTC) medicines for cough and colds contain DXM. It’s in Coricidin, Dimetapp DM, Nyquil, Robitussin Cough and Cold, and store brands for cough-and-cold medicines. These products are available in pharmacies, grocery stores, and other retail outlets. A safe dose of products with DXM is about 15-30 milligrams (mg) over 24 hours. It usually takes 10 times that amount to make a teenager high.

Teen DXM Slang

A syrup head is someone using cough syrups with DXM to get high. Dexing is getting high on products with DXM. Orange Crush alludes to some cough medicines with DXM. (The name may stem from the orange-colored syrup—and packaging—Delsym.)

Poor man’s PCP and poor man’s X are also common terms, because these drugs are inexpensive, but can cause effects similar to PCP or ecstasy at high doses. Red devils refer to Coricidin tablets or other cough medicines. Robo usually refers to cough syrup with DXM. It derives from the brand name Robitussin but is common slang for any cough syrup. Robo-tripping alludes to abusing products with DXM and, specifically, to the hallucinogenic trips people can attain at high doses.

Parents who hear teens using these terms should ask questions when the child and parent are alone.

Prevalence and Trends

The Monitoring the Future (MTF) survey, conducted by the National Institute on Drug Abuse (NIDA) and the University of Michigan, provides insights into adolescent substance use. The survey began monitoring OTC cough-and-cold medication abuse every year in 2006. That year, the MTF reported that 4.2% of 8th-graders, 5.3% of 10th-graders, and 6.9% of 12th-graders misused OTC cough-and-cold medications in the previous year. In 2015, 2.6% of 8th-graders, 3.3% of 10th-graders, and 4.0% of 12th-graders reported past-year misuse. The most recent data, in 2024, indicate that the percentage dropped somewhat. However, a recent alert from the National Drug Early Warning System at the University of Florida (NDEWS) suggests a resurgence of interest in DXM and its combination with antihistamines.

DXM+ Combination Dangers

When taken alone, DXM’s dissociative and hallucinogenic effects may include euphoria, altered perception of time, paranoia, disorientation, and hallucinations. Physical symptoms of intoxication are hyperexcitability, problems walking, involuntary eye movements, and irritability. High doses can lead to impaired motor function, numbness, nausea and vomiting, increased heart rate, and elevated blood pressure. Chronic misuse results in dependence and severe psychological or physical health issues.

Combining DXM with other substances, especially alcohol, sleeping pills, antihistamines, or tranquilizers, is highly risky, as is combining DXM with antidepressants affecting serotonin, due to the risk of a possibly life-threatening serotonin syndrome.

Combining DXM With Promethazine

Combining the abuse of the prescribed antihistamine promethazine (Phenergan) with DXM may be increasing. The recent alert from the National Drug Early Warning System suggested that this new combination is an emerging threat.

The NDEWS recently checked for recent reports of saccharine (artificial sugar) being detected in abused drugs. Putting on their detective hats, the NDEWS team discovered that increased saccharine in drugs was caused by users adding cough syrup to promethazine. The signal for this combination was detected in more than double the number noted in early 2024.

Combining DXM and promethazine can amplify central nervous system depression, leading to increased drowsiness, dizziness, and impaired motor function. High doses may cause aggression, severe respiratory depression, hallucinations, delirium, paranoia, and cognitive impairments. Reddit social media reports noted an increased risks of falls and injuries due to severely impaired coordination and balance from the DXM-and-promethazine combination.

Promethazine with codeine is still available by prescription in the U.S., but access is restricted due to its classification as a Schedule V controlled substance at the federal level. Pharmacies and healthcare providers have become more cautious in prescribing promethazine with codeine due to its association with recreational use. Some manufacturers have discontinued production of promethazine with codeine, but generic versions remain on the market under tight regulation.

Purple drank is drug slang for the mixture containing codeine and promethazine mixed with a soft drink such as Sprite or Fanta—and sometimes with candy such as Jolly Ranchers. The drink gets its name from the purple color of some cough syrups. Purple drank has been popularized in certain music and hip-hop cultures, with some artists glorifying its use in their lyrics. However, many rappers who once promoted the drug later warned against its dangers after experiencing serious health consequences themselves or witnessing peers suffer from addiction and overdoses.

Professor Linda Cottler, Ph.D., M.P.H., director of NDEWS. commented: “Healthcare professionals should be aware of the potential for abuse and monitor for signs in patients, especially adolescents and young adults,” Linda added: “Parents should be aware of these combinations and talk to their children about avoiding “cough” medicines acquired from friends, friend’s siblings, or friends’ parents.”

Summary

While the combination of DXM and promethazine is not commonly reported in drug abuse or emergency-room cases, misuse could lead to significant health risks. Stores have started to keep these cough and cold remedies behind the counter to reduce access and potential for teen abuse. Some makers of OTC medicines with DXM have put warning labels on their packaging about the potential for abuse. Many states have banned sales of meds with DXM to minors. These actions have helped reduce teen DXM abuse. However, recent teen interest in abuse of combined DXM and promethazine is concerning.

Source: https://www.psychologytoday.com/us/blog/addiction-outlook/202502/teenage-abuse-of-cough-medicines-and-promethazine

Filed under: Addiction,Drug use-various effects,Medicines,Mental Health,Prescription Drugs,Prevention and Intervention,Treatment and Addiction,USA,Youth :

Guillaume Airagnes

Lecturer at Universite Paris Cite

Amine Benyamina

Professor at Paris Saclay Faculty of Medicine

assisted by Sophie Podevin

Journaliste Scientifique, Ginkio

Key points:

As the leading cause of a deregulation in the brain’s reward circuit, addictions are still widespread among the French population. This is largely due to the widespread use of legal psychoactive substances: tobacco and alcohol, which are the two leading causes of premature death in France. In 2020, nearly 25.5% of adults smoked every day (12 million people) and 10% drank at least one glass of alcohol a day (5 million people). So, what is the situation for substance addictions in France for the coming year?

A restricted definition

First of all, to qualify as an addiction, a person must meet at least 2 of the 11 criteria set out in the Diagnostic and Statistical Manual of Mental Disorders (DSM‑5), including: craving, a compelling need to consume the substance or perform the activity; loss of control over the quantity and time devoted to consumption; increased tolerance to the product; a strong desire to reduce doses; continued use despite the damage; or the presence of a withdrawal syndrome when the addictive behaviour is abruptly stopped…

To date, only addictions to substances (tobacco, alcohol, cannabis, cocaine, opium and derivatives) or to video games and gambling are recognised as “addictions”. Social networking, sexual hyperactivity and sugar are not considered as such due to a lack of data and scientific evidence.

Top three

In France, the most widely used addictive substances are still tobacco, alcohol and cannabis. The first two are responsible for 75,000 and 41,000 deaths a year respectively. These are terrifying figures, known but ignored because of habit.

In an article published on 20 October 2024, Doctor Bernard Basset, chairman of the Addictions France association, and psychiatrist and addictologist Amine Benyamina, chairman of the Fédération Française d’Addictologie (FFA), proposed a series of measures combining public health and government debt, such as taxing drinks according to their alcohol content, or introducing a minimum price per drink based on the Scottish model. “In France, we have a real cultural problem with alcohol and very powerful lobbies,” says Amine Benyamina. “All public prevention policies are stifled or censored.” And yet, according to data collected by the Constances epidemiological cohort, which numbered almost 200,000 people in 2018, 19.8% of men and 8% of women in the working population are thought to have a harmful use of alcohol.

While the problem persists, it is changing. Starting with a major positive point made by Guillaume Airagnes, Director of the French Observatory of Drugs and Addictive Tendencies (OFDT) and Doctor of Psychiatry and Addictology: “The general consumption of substances such as tobacco and alcohol has been falling among young people since 2010.” However, there was a downside at the time of Covid, when several addictive activities were on the increase during confinement.

On the other hand, a clear increase in the use of psychostimulant drugs has been observed among adults since 2010, “although the levels of use in the general population remain incomparably lower than those for tobacco, alcohol or cannabis” points out Guillaume Airagnes.

These substances, like ecstasy, have benefited from their image becoming much more commonplace. This is also the case for cocaine, the availability of which has risen steadily over the last ten years, and which used to be the social marker of a wealthy economic category. In 2021, 26.5 tonnes of cocaine were seized, a 67% increase on 2018. “Cocaine benefits from the tenacious stereotype that it does not produce dependence. In reality, while the signs of physical withdrawal are almost non-existent, it is one of the most psychologically tyrannical substances, with extremely powerful cravings,” describes Amine Benyamina, who is also head of the psychiatry and addictology department at the Paul-Brousse hospital in Paris. This increase is set to continue. The 2020 lockdowns demonstrated the adaptability of the drug trade, with home delivery services, marketing, attractive packaging, the use of social networks and instant messaging, and even payments in cryptocurrency.

Misuse of medicines as a new drug

Another less well-known development is the misuse of certain opiate-based drugs, such as codeine or tramadol, which are intended for therapeutic purposes. These are morphine derivatives with a less powerful analgesic effect than morphine. “Paradoxically, this makes them more addictive,” explains Guillaume Airagnes. “As the psychoactive effects are less intense, this leads to greater compulsive consumption.” Misuse of these drugs has been documented for around ten years and remains under close surveillance, although it still only concerns a “very small proportion of users” the director of the OFDT points out.

In his department, Amine Benyamina also sees new types of drug misuse: “More marginal but just as problematic is the use of pregabalin or LYRICA. This is a product designed to treat neuropathic pain or post-traumatic stress syndromes.” This analgesic, which this time is not a morphine derivative, also has a strong addictive potential, encouraging patients to continue taking it beyond the prescription period.

One of the first problems facing carers is the lack of information about drug users themselves. In fact, most of the data on addiction in France comes from surveys carried out on the general population to be more representative. But not for much longer! In April 2024, the first national e‑cohort open only to drug users was launched: ComPaRe Pratiques Addictives. “We already have several thousand subscribers,” says Guillaume Airagnes, who is heading up the study. “The only condition to be eligible is to be a psychoactive substance user at the time of inclusion in the study. Of course, our aim is to follow up participants for at least 5 years, regardless of whether they continue to use substances.”

The responses and the long-term follow-up will enable Guillaume Airagnes and his teams to explore several avenues of research: the question of multiple drug use, which seems to be the rule rather than the exception; the relationship between drug use and economic, demographic or professional situation; the study of the very strong stigmatisation phenomenon among these users, etc. These data will also enable us to better target effective therapies that are adapted to each profile.

In its Guide pratique de psychothérapies les plus utilisées en addictologie of May 2022, the Fédération Française d’Addictologie lists and ranks the different therapies according to their clinical relevance. The behavioural and cognitive therapy (BCT) approach remains the most popular, with a method that can be adapted to addictions with and without substances and solid results confirmed by scientific studies.

But other avenues of treatment are being explored, such as the surprising use of LSD derivatives. “The initial results are surprising and encouraging,” says Professor Amine Benyamina with satisfaction. “Of course, it’s important to remember that these studies are very closely supervised” warns the professor, who is working with his team on the effect of psilocybin on alcohol addiction. “They should not be reproduced at home!”

Filed under: Addiction,Europe,Medicines :