Polysubstance mortality trends in White and Black Americans during the opioid epidemic, 1999-2018

Abstract

Background: Psychoactive drug combinations are increasingly contributing to overdose deaths among White and Black Americans. To understand the evolving nature of overdose crisis, inform policies, and develop tailored and equitable interventions, this study provides a comprehensive assessment of polysubstance mortality trends by race and sex during the opioid epidemic.

Methods: We used serial cross-sectional US mortality data for White and Black populations from 1999 through 2018 to calculate annual age-adjusted death rates (AADR) involving any opioid, opioid subtypes, benzodiazepines, cocaine, psychostimulants, or combinations of these drugs, stratified by race and sex. Trend changes in AADR were analyzed using joinpoint regression models and expressed as average annual percent change (AAPC) during each period of the three waves of the opioid epidemic: 1999-2010 (wave 1), 2010-2013 (wave 2), and 2013-2018 (wave 3). Prevalence measures assessed the percent co-involvement of an investigated drug in the overall death from another drug.

Results: Polysubstance mortality has shifted from a modest rise in death rates due to benzodiazepine-opioid overdoses among White persons (wave 1) to a substantial increase in death rates due to illicit drug combinations impacting both White and Black populations (wave 3). Concurrent cocaine-opioid use had the highest polysubstance mortality rates in 2018 among Black (5.28 per 100,000) and White (3.53 per 100,000) persons. The steepest increase in death rates during wave 3 was observed across all psychoactive drugs when combined with synthetic opioids in both racial groups. Since 2013, Black persons have died faster from cocaine-opioid and psychostimulant-opioid overdoses. Between 2013 and 2018, opioids were highly prevalent in cocaine-related deaths, increasing by 33% in White persons compared to 135% in Blacks. By 2018, opioids contributed to approximately half of psychostimulant and 85% of benzodiazepine fatal overdoses in both groups. The magnitude and type of drug combinations with the highest death rates differed by race and sex, with Black men exhibiting the highest overdose burden beginning in 2013.

Conclusions: The current drug crisis should be considered in the context of polysubstance use. Effective measures and policies are needed to curb synthetic opioid-involved deaths and address disparate mortality rates in Black communities.

Keywords: Benzodiazepines; Joinpoint trend analysis; Opioids; Polysubstance mortality; Racial disparities; Stimulants.

Fig. 1

Mortality trends from (A) cocaine, (B) benzodiazepines, and (C) psychostimulants overall and in combination with opioids by race, 1999–2018. Notes: Dots represent observed age-adjusted death rates, while solid lines represent modeled rates. Trend segments were fitted using joinpoint regression modeling. Segments are connected at joinpoints denoting years of significant changes in trend. The slope of each segment represents the Annual Percent Change (APC). Vertical dashed lines at 2010 and 2013 mark the beginning of the second and the third waves of the opioid epidemic, respectively. Death rates were calculated per 100,000 population and adjusted to the 2000 US standard population. Overall mortality from a specific drug is all deaths involving this drug whether alone or when combined with any other drug of abuse. Data are from the Centers for Disease Control and Prevention [32, 35]

Fig. 2

Mortality trends due to combinations of opioids and other psychoactive drugs by opioid subtype and race, 1999–2018. Notes: Dots represent observed age-adjusted death rates, while solid lines represent modeled rates. Trend segments were fitted using joinpoint regression modeling. Segments are connected at joinpoints denoting years of significant changes in trend. Death rates were calculated per 100,000 population and adjusted to the 2000 US standard population. Opioid subtypes are heroin, prescription opioids, and synthetic opioids. Data are from the Centers for Disease Control and Prevention [32, 35]

Fig. 3

Percent of opioid co-involvement in all deaths due to (A) Cocaine, (B) Benzodiazepines, and (C) Psychostimulants by opioid subtype and race, 1999–2018. Note: Data are form the Centers for Disease Control and Prevention [32]