Yellow pillss on a blue table

Researchers warn of next ‘wave’ of opioid overdose deaths

Case Western Reserve University and Cuyahoga County Medical Examiner’s Office on front lines of another epidemic plaguing nation

When Cuyahoga County Medical Examiner Thomas Gilson issued a public health warning earlier this month, the cause wasn’t COVID-19—but drugs.

Over a 48-hour period Nov. 6 and 7, he reported, a dozen people died of overdoses; at the current rate the county could be on pace to see 700 more drug fatalities before December’s end.

The tragic news is only the most recent jarring development in the state’s efforts to reverse devastating trends.  Between May 2020 and April 2021, more than 5,500 Ohio residents died from opioid overdose—an increase of more than 1,000 fatalities from the same timeframe the previous year.

A team of researchers from Case Western Reserve University and the Cuyahoga County Medical Examiner’s Office played a key role in collecting and analyzing the Ohio data. Daniel Flannery, the Semi J. and Ruth W. Begun Professor at Case Western Reserve’s Jack, Joseph and Morton Mandel School of Applied Social Sciences, predicted the nation is in the throes of the opioid epidemic’s next wave. And, worse, it’s defined by the continuing rise of much stronger and more lethal fentanyl.

Photo of Dan Flannery
Daniel Flannery, the Semi J. and Ruth W. Begun Professor at the Mandel School and the director of the Begun Center

“This epidemic can be framed in waves, starting prior to 2010 that began to rise, then plateau,” said Flannery, who also directs the university’s Begun Center for Violence Prevention Research and Education. “The trend was largely focused around overdose deaths from prescription opioid pain relievers. Next came heroin. Wave three began in 2014, with an increase in illicitly manufactured fentanyl, often present in mixtures with heroin and cocaine.” 

Earlier this year Flannery and the research team published their findings in the International Association of Chiefs of Police magazine, Police Chief. They highlighted that the fourth wave occurred in 2017—one in which preliminary data indicates a massive spike in carfentanil-related deaths. In Cuyahoga County, 727 people died from overdose in 2017, a record high.

“A significant number of those who died of an overdose also had more than one drug in their system,” he said. “Ohio has the unfortunate distinction of ranking in the top five (states) in opioid-related deaths in the nation… We’re really on the front lines here. This work really gives us the opportunity to make an impact locally.”

Unfortunately, many more states also are experiencing such increases. According to the Centers for Disease Control and Prevention, more than 100,000 people died of drug overdoses in the United States during the May 2020 to April 2021 time period—up more than 28% from the year before. More than three-fourths of those deaths were from opioids.

In Cuyahoga County, deaths are up more than 30% from last year and are on pace to overtake the record number of deaths in 2017. In 2021, overdose deaths are primarily due to fentanyl mixed with cocaine and methamphetamines—often present in illicit counterfeit pills—without the user necessarily being aware, Flannery said.  


As part of the study, researchers interviewed 40 professionals—including medicolegal investigators, police detectives, prosecutors and investigators from local and federal agencies—to identify some of the challenges facing law enforcement to investigate overdoses and prosecute traffickers. 

Flannery said their research highlighted the need to improve rapid testing for fentanyl, as well as the need for fentanyl test strips made available to users. He also recommended better communication between police and social workers, which would help addicts in the recovery process—instead of incarceration.

“We also need to have naloxone (a medicine that rapidly reverses the effects of opioids) near high-incident locations, more Drug Take Back locations and increased availability of needle exchanges,” he said. “There are many more backstops than there were three years ago; you hate to think it could be worse if not for the efforts so far. If people choose to use, then do not use alone, use your fentanyl test strips and make sure you have naloxone (Narcan) readily available in case of an accidental overdose.”

Flannery was joined in the research by Cuyahoga County Medical Examiner Thomas Gilson; Manreet Bhullar, forensic epidemiologist for Cuyahoga County Medical Examiner’s Office; and Ivette Noriega, a postdoctoral researcher at the Begun Center.

If possible, those struggling with addiction should consult their doctor. Those seeking confidential, free help from public health agencies—and to find substance use treatment information—are encouraged to visit or call the Substance Abuse and Mental Health Services Administration (SAMSHA) national helpline at 1.800.662.4357.

For more information, contact Colin McEwen at