Understanding and Addressing Widening Racial Inequalities in Drug Overdose

Abstract

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.

Keywords: Disparities; Opioids; Substance-Related and Addictive Disorders.

Figure 1.. Drug Overdose Mortality by Race/Ethnicity, 1999–2022

Year-to-year percent change in drug overdose mortality by race/ethnicity (top). Drug overdose mortality per 100,000 population by race/ethnicity (bottom). All data were obtained from CDC WONDER. Records from 2022 are provisional and trends may change slightly in final numbers.

Figure 2.. Overall and Race/Ethnicity Trends in the Four Waves of the Overdose Crisis

(Left) A simplified representation of the four waves of the United States overdose mortality crisis. The arrows at the bottom of the graph highlight the onset year of each wave. W1 = Wave 1, starting in the early 2000s, represented by deaths involving prescription opioids (shown here with fentanyl-involved deaths removed). W2 = Wave 2, starting in 2010, represented by deaths involving heroin opioids (shown here with fentanyl-involved deaths removed). W3 = Wave 3, starting in 2013, represented by deaths involving fentanyl and other synthetic opioids (shown here with stimulant-involved deaths removed). W4 = Wave 4, starting in 2015, represented by deaths involving fentanyl and stimulants. (Right) Trends by racial/ethnic group in each wave of the overdose crisis. Each racial/ethnic group is shown by color, separately for each wave of the overdose crisis (as defined in the left panel). All data were obtained from CDC WONDER. Records from 2022 are provisional and trends may change slightly in final numbers.

Figure 3.. Racial Differences in Age-Period-Cohort Dynamics in the US Overdose Crisis

(Top) Drug overdose mortality per 100,000 population by race/ethnicity is shown for ten-year age groups from 15–24 to 65–74, with progression over year, for the years 1999 to 2022. (Bottom) Drug overdose mortality per 100,000 population is shown for single year birth cohorts spanning 1940–2022, with progression over age, with color corresponding to the decade of each birth cohort. All data were obtained from CDC WONDER. Records from 2022 are provisional and trends may change slightly in final numbers.

Figure 4.. State-Level Ratio of Overdose Deaths Among Minoritized Groups to Non-Hispanic White Individuals, 2010, 2015, and 2022

The ratio of drug overdose mortality per 100,000 population among four minoritized groups, compared to Non-Hispanic White individuals, at the state-level, in 2010, 2015, and 2019. Points are only shown for all state-years with sufficient number of overdose deaths to make a comparison. A vertical dashed line highlights a ratio of 1.0, indicating the same rate as Non-Hispanic White individuals. All data were obtained from CDC WONDER. Records from 2022 are provisional and trends may change slightly in final numbers.