The fourth wave of the United States overdose crisis—driven by the polysubstance use of fentanyl with stimulants and other synthetic substances—has driven sharply escalating racial/ethnic inequalities in drug overdose death rates. Here the authors present a detailed portrait of the latest overdose trends and synthesize the literature to describe where, how, and why these inequalities are worsening. By 2022 overdose deaths among Native and Black Americans rose to 1.8 and 1.4 times the rate seen among White Americans, respectively. This reflects that Black and Native Americans have been disproportionately affected by fentanyl and the combination of fentanyl and stimulants at the national level and in virtually every state. The highest overdose deaths rates are currently seen among Black Americans 55–64 years of age as well as younger cohorts of Native Americans 25–44 years of age. In 2022—the latest year of data available—deaths among White Americans decreased relative to 2021, whereas rates among all other groups assessed continued to rise. Moving forward, Fundamental Cause Theory shows us a relevant universal truth of implementation science: in socially unequal societies, new technologies typically end up favoring more privileged groups first, thereby widening inequalities unless underlying social inequalities are addressed. Therefore, interventions designed to reduce addiction and overdose death rates that are not explicitly designed to also improve racial/ethnic inequalities will often unintentionally end up worsening them. Well-funded community-based programs, with Black and Native leadership, providing harm reduction resources, naloxone, and medications for opioid use disorder in the context of comprehensive, culturally appropriate healthcare and other services, represent the highest priority interventions to decrease inequalities.

美国第四波药物过量危机——由芬太尼与兴奋剂和其他合成物质的多物质使用引发——导致药物过量死亡率的种族/民族不平等急剧升级。在这里，作者详细描述了最新的用药过量趋势，并综合文献来描述这些不平等现象在何处、如何以及为何恶化。到 2022 年，美国原住民和黑人的服药过量死亡率分别上升到美国白人的 1.8 和 1.4 倍。这反映出，在国家层面和几乎每个州，黑人和美洲原住民都受到芬太尼以及芬太尼和兴奋剂组合的不成比例的影响。目前，55-64 岁的美国黑人以及 25-44 岁的年轻美国原住民群体中服药过量死亡率最高。 2022 年（可获得数据的最新一年），美国白人的死亡率相对 2021 年有所下降，而所有其他接受评估的群体的死亡率则继续上升。展望未来，根本原因理论向我们展示了实施科学的一个相关普遍真理：在社会不平等的社会中，新技术通常最终首先有利于更有特权的群体，从而扩大不平等，除非根本的社会不平等得到解决。因此，旨在降低成瘾和服药过量死亡率的干预措施，如果没有明确旨在改善种族/民族不平等，往往会无意中导致情况恶化。资金充足、以社区为基础的计划，由黑人和原住民领导，在全面的、文化上适当的医疗保健和其他服务的背景下提供减少危害的资源、纳洛酮和治疗阿片类药物使用障碍的药物，是减少不平等的最优先干预措施。