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Published in final edited form as: Drug Alcohol Depend. 2023 Jun 20;249:109946. doi: 10.1016/j.drugalcdep.2023.109946

Opioid and Stimulant Attributed Treatment Admissions and Fatal Overdoses: Using National Surveillance Data to Examine the Intersection of Race, Sex, and Polysubstance Use, 1992-2020

AA Jones 1,2, RD Shearer 3, JE Segel 2,4,5, A Santos-Lozada 1, S Strong-Jones 1, N Vest 6, D Teixeira da Silva 7, UG Khatri 8,9, TNA Winkelman 10,11
PMCID: PMC10375360  NIHMSID: NIHMS1913338  PMID: 37354584

Abstract

Background:

We use national surveillance data to evaluate race/ethnicity by sex/gender differences and trends in substance use treatment admissions and overdose deaths involving opioid and stimulant use.

Methods:

We used data (1992-2019) from the Treatment Episode Dataset-Admissions to identify treatment admissions and the Center for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research (1999-2020) to identify overdose deaths. We assessed treatment admissions and related drug overdose deaths per 100,000 adults by sex and race/ethnicity for opioid and stimulant groups: cocaine, opioid, methamphetamines, cocaine and opioid use, cocaine and methamphetamines, and opioid and methamphetamines.

Results:

We found significant variations in treatment admissions and deaths by race/ethnicity and sex/gender. Cocaine-related treatment admissions and deaths were most prevalent among Non-Hispanic Black individuals over the study years, yet lower rates were evident among individuals from other racial/ethnic groups. Notably, Non-Hispanic Black men experienced larger increases in cocaine-only admissions than men of other racial/ethnic groups between 1992 and 2019. Men had higher opioid and stimulant treatment admissions and overdose deaths than women. We observed skyrocketing methamphetamine deaths among American Indian/Native Alaskan men and women from 1992 to 2019.

Discussion:

Steep increases in overdose deaths fueled by methamphetamines among Non-Hispanic Native Americans and cocaine among Non-Hispanic Black individuals suggest a need for more effective interventions to curb stimulant use. Variations by race/ethnicity and sex/gender also suggest interventions should be developed through an intersectionality lens.

1. Introduction

1.1. Opioids, Stimulants, and the Overdose Crisis

The U.S. overdose crisis is increasingly severe, with over 100,000 drug overdose deaths in 2020 (Jones et al., 2023a; CDC, 2021; Ahmad et al., 2021; Han et al., 2021; Cano et al., 2021), particularly related to increases in synthetic opioids (e.g., fentanyl) and stimulants (e.g., cocaine and methamphetamine) (Ciccarone, 2021; Mattson et al., 2021; Han et al., 2021; Cano et al., 2021; Shearer et al., 2020). Epidemiological data show that age-adjusted drug overdose deaths involving methamphetamines increased by 500% from 2012-2018 (Han et al., 2021). Similarly, cocaine-involved deaths increased by nearly 300% (2.14 in 2002 vs. 6.03 in 2018), despite no significant increase in cocaine use during the same period (Cano, Salas-Wright, Vaughn, 2020). While it is known that drug overdose deaths and the need for drug treatment are increasing, data disaggregated by race/ethnicity and sex/gender, and assessed in comparison to prior decades of data, are limited and warrant additional focus (El-Bassel & Shoptaw, 2021).

1.2. Sex/Gender Differences in Substance Use, Treatment, and Overdoses

Disaggregated drug treatment and overdose deaths by sex/gender are crucial as the trajectories of women who use drugs differ from their male counterparts (Harris, 2022). Women may progress to addiction sooner, be more likely to relapse, be more sensitive to the effects of drug use due to sex hormones, and be more likely to experience a fatal overdose (Carmichael et al., 2022; NIDA, 2021). Although women comprise a third of those with substance use disorders, women represent only a fifth of those in substance use treatment, suggesting sex/gender-specific barriers to treatment (Meyer et al., 2019). Deaths involving multiple substances have also increased among women. In 1999, 25% of drug overdose deaths among women involved more than one substance, which increased to 52% by 2017 (Carmichael et al., 2022). As the drug overdose epidemic is exacerbated by the rise in overdose deaths involving opioids and stimulants, it is imperative to understand specific trends among women to develop sex/gender-responsive interventions (Mattson et al., 2021; Appa et al., 2021; Carmicheal et al., 2022).

1.3. Race/Ethnic Differences in Substance Use, Treatment, and Overdoses

Racial and ethnic disparities in overdose deaths are increasingly evident (Friedman & Hansen et al., 2022a; Khatri et al., 2021). In 2018, while overdose deaths decreased among Non-Hispanic White men and women, they continued to increase for Hispanic and Black men and women (Ciccarone, 2021). While the use of stimulants, like methamphetamine, has increased for all racial groups, American Indian/Alaskan Native (AI/AN) individuals had the highest age-adjusted rate of psychostimulant overdose deaths in 2018. Non-Hispanic Black men had the fastest increase in psychostimulant overdose deaths between 2012-2018 (Cano et al., 2021; Han et al., 2021). Despite unvarying past year use of cocaine, Black individuals had a significantly higher rate of cocaine-involved overdose deaths than White individuals from 2007-2019 (Townsend et al., 2022; Cano, Salas-Wright, Vaughn, 2020; Cano et al., 2021).

The COVID-19 pandemic exacerbated overdose deaths due to any substance, with racial disparities increasing, particularly among Black and AI/AN individuals (Jones et al., 2023a; Han et al., 2022; Liu et al., 2022).). The increase in these deaths may be attributed to increased social isolation and engaging in drug use alone, stress and economic distress due to pandemic-related uncertainties, limited access to treatment and harm reduction measures, and tainted drug supplies attributed to the border closures (Liu et al., 2022; Sacco et al., 2022; Macmadu et al., 2021). Tainted drug supplies, particularly synthetic opioids, have contributed to the rise in overdose deaths, with varying impacts across regions (Gryczynski et al., 2019; Rhodes et al., 2019; Chandra et al., 2021).

Moreover, Black individuals are less likely to receive substance use treatment for cocaine and opioid use (Lewis et al., 2018; Wu et al., 2018) and less likely to complete treatment than White individuals, which was attributed to several social disadvantage factors (Shearer et al., 2020; Mennis et al., 2019; Williams & Cooper, 2019; Dasgupta et al., 2018). Pro and colleagues (2018) found that the strongest correlate of substance use treatment outcomes was community distress, which incorporated poverty, poor educational systems, low incomes, and unemployment. Lower community distress was linked with positive treatment outcomes, and racially/ethnically minoritized individuals seeking SUD treatment were more likely to come from distressed communities.

1.4. Current Study

Current research assessing race by sex differences in overdose and substance use treatment trends is limited to specific substances, geographic areas, and age categories, and does not include the most recent years of this overdose epidemic (Lim et al., 2021; Han et al., 2021; Appa et al., 2021). While Spencer et al. (2022) examined overdose mortality by substance for gender and race/ethnicity separately, they did not examine treatment or the intersection of gender and race/ethnicity. Yet, changes in trends for women of racially/ethnically minoritized groups are critical to demonstrating important intersectional differences (Meyer et al., 2019). We use national surveillance data to evaluate race by sex/gender differences and trends in substance use treatment admissions and overdose deaths for patterns of opioid and stimulants (cocaine and methamphetamine).

2. Methods

2.1. National Surveillance Data

We used Treatment Episode Dataset-Admissions (TEDS-A) data to identify opioid and stimulant treatment admissions and the Center for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) to identify opioid and stimulant-involved deaths.

The TEDS-A is collected by the Substance Abuse and Mental Health Services Administration (SAMHSA) since 1992 to assess trends of treatment admissions by drug types. We identified treatment admissions that indicated opioids (heroin, non-prescription methadone, and other opioids/synthetic opioids), methamphetamine, and/or cocaine as primary, secondary, or tertiary substances leading to admission. We then categorized these treatment admissions into mutually exclusive groups: cocaine only, opioid only, methamphetamines only, cocaine and opioid, cocaine and methamphetamines, and opioid and methamphetamines.

CDC WONDER was used to assess trends of drug overdose deaths, including opioids and stimulants (1999-2020). We used ICD-10 codes: X40–X44, X60–X64, X85, and Y10–Y14 to identify drug overdose deaths. We used the code T40.5 for cocaine-related deaths, T40.0-T40.4, T40.6 for opioid-related deaths, and T43.6 to identify psychostimulants with abuse potential (which predominantly includes methamphetamine (Han et al., 2021) and so we refer to this category as methamphetamine-related deaths throughout). To evaluate trends in drug overdose deaths over time, we assessed any deaths attributed to cocaine, any deaths attributed to opioids, and any deaths attributed to methamphetamines. We then assessed deaths attributed to patterns of opioid and stimulant use: any deaths involving cocaine and opioids, any deaths involving cocaine and methamphetamines, and any deaths involving opioids and methamphetamines. While CDC WONDER allows for identifying overdose deaths involving particular substances, it does not allow us to exclude other substances that may be implicated in those deaths (ex: opioid-involved deaths but no other drugs implicated in those deaths). Thus, our trends in drug overdose deaths are not mutually exclusive.

2.2. Race/Ethnicity and Sex

TEDS-A data includes participants’ biological sex and race/ethnicity reported at treatment admission, and CDC WONDER includes the decedent’s biological sex and race/ethnicity as reported by family members or determined by the coroner when the family is not available. For this study, the social construct of race/ethnicity was categorized into mutually exclusive categories: Hispanic, Non-Hispanic White, Non-Hispanic Black, Non-Hispanic Asian or Pacific Islander, and Non-Hispanic AI/AN.

2.3. Statistical Analysis

We defined treatment admissions and overdose death rates as treatment admissions and overdose deaths per 100,000 individuals across the various patterns of cocaine, opioids, and methamphetamine each year, stratified by sex/gender and race/ethnicity. CDC WONDER’s Census population estimates by race/ethnicity and sex/gender were used. We then plotted trends in treatment admissions for adults age 18 and older (1992-2019) and mortality rates for all individuals (1999-2020) by opioid and stimulant patterns and race/ethnic and sex groups. All analyses and visualizations were completed using R Version X (R Core Team, 2021). Due to large variations in rates by race/ethnicity, using consistent y-axes for all race/ethnicity groups limits the readability of the figures (Figures 1 and 2). We report figures with consistent y-axes for the most recent 5 years of data as supplemental information (Supplemental Figures 1 and 2). We used publicly available and de-identified data, exempting this study from formal Institutional Review Board review.

Figure 1:

Figure 1:

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Trends in Opioid and Stimulant Treatment Admissions for Males in the United States, 1992-2019

Figure 2:

Figure 2:

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Trends in Opioid and Stimulant Treatment for Females in the United States, 1992-2019

3. Results

3.1. Overall Descriptive Statistics

Our study utilized N=24,899,289 drug treatment admissions data in the TEDS-A data set (1992-2019). Of these admissions, 63.5% were males, 36.5% were females; 14.5% were Hispanic, 57.4% were Non-Hispanic White, 26.0% were Non-Hispanic Black, 0.65% Non-Hispanic Asian or Pacific Islander, 1.43% were Non-Hispanic AI/AN. Overall, admissions to drug treatment in the sample were due to opioids only (32.4%), cocaine only (34.9%), methamphetamine only (12.9%), cocaine and opioids (15.0%), methamphetamines and opioids (2.9%), and cocaine and methamphetamines (1.6%).

Regarding drug overdose mortality, there were N=583,408 decedents who died from opioid or stimulant-related deaths from 1999-2020. Approximately 68.1% of decedents were males. Overall, 96.8% of deaths in the sample involved opioids, 27.6% involved cocaine, and 17.7% involved methamphetamine. Involvement of multiple substances was common; 17.2% of deaths involved both opioids and cocaine, 8.7% involved both opioids and cocaine, and 1.8% involved both methamphetamine and cocaine

3.2. Trends in Opioid and Stimulant Treatment Admissions for Males in the United States, 1992-2019

We observed different patterns across race/ethnicity groups for opioid and stimulant treatment rates among males between 1992-2019 (Figures 1-4). First, Non-Hispanic Black men had dramatically higher rates of cocaine-only treatment, although this fell to under 250 per 100,000 in 2015. Opioid-only treatment rates were also higher among Non-Hispanic Black men (1999: 140 per 100,000; 2020: 211 per than among Non-Hispanic White men over this period (1999: 74 per 100,000; 2020: 165 per 100,00). However, we observed a large increase in opioid treatment rates for Non-Hispanic White men over this period; additionally, we observed more steady increases (albeit at a lower level) for methamphetamine only, cocaine and methamphetamine, and opioid and methamphetamine treatment for Non-Hispanic White men. For Non-Hispanic Asian or Pacific Islander men, we observed increased treatment for opioid-only and methamphetamine, but rates were significantly lower compared to other racial/ethnic groups. Non-Hispanic AI/AN men experienced the highest treatment rates for methamphetamine only; they also had an increase in opioid-only and opioid and methamphetamine treatment between 2005 and 2019. Hispanic men had an earlier peak in opioid-only treatment but saw declines in opioid-only treatment, unlike other racial/ethnic groups. They also experienced consistent declines in cocaine-only and opioid and cocaine treatment but increased methamphetamine-only treatment. Across all groups, cocaine and methamphetamine treatment rates were low.

Figure 4:

Figure 4:

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Trends in Opioid and Stimulant Mortality for Females in the United States, 1999-2020

3.3. Trends in Opioid and Stimulant Treatment for Females in the United States, 1992-2019

Overall, we observed fairly similar patterns of substance-related treatment for women compared to men, with similar differences across racial/ethnic groups. Like Non-Hispanic Black men, Non-Hispanic Black women had significantly higher cocaine treatment rates that peaked at around 450 per 100,000 in 1993 and then declined consistently until 2015, as well as a modest increase in opioid-only and opioid and cocaine treatment between 2015 and 2019. Similar to Non-Hispanic White men, Non-Hispanic White women experienced a large increase in opioid-only treatment around 2007, although at a lower nominal level. However, unlike men, Non-Hispanic White women experienced more modest increases in methamphetamine-only treatment and opioid and cocaine treatment. Similar to men, Non-Hispanic Asian or Pacific Islander women had significantly lower treatment rates across all substance types than other racial/ethnic groups. Non-Hispanic AI/AN women had the highest rates of methamphetamine treatment. They also experienced an increase in opioid-only treatment that began to drop around 2012 and consistent drops over time in cocaine-only treatment. Finally, Hispanic women, unlike Hispanic men and other racial/ethnic groups, experienced fairly flat treatment rates across all substances.

3.4. Trends in Opioid and Stimulant Mortality for Males in the United States, 1999-2020

The rate of any opioid-related deaths increased among males of all races/ethnicities, including a steep increase from 2019 to 2020; Non-Hispanic Black men (1999: 5.3 per 100,000; 2020: 40.8 deaths per 100,000), Non-Hispanic White men (1999: 4.3 per 100,000; 2020: 33.1 per 100,000) Non-Hispanic Asian or Pacific Islander (1999: 0.4 per 100,000; 2020: 5.3 per 100,000), Non-Hispanic AI/AN (1999: 3.6 per 100,000; 2020: 34.0 per 100,000), and Hispanic men (1999: 5.2 per 100,000; 2020: 20.7 per 100,000). Opioid-related deaths increased by over 600% among Non-Hispanic Black, White, AI/AN, and Asian men and nearly 400% among Hispanic men.

Among male decedents, Non-Hispanic Black men had the highest rate of cocaine-related deaths (1999: 5.6 per 100,000; 2020: 21.6 per 100,000) and experienced increases in overdose mortality for each substance-related category from about 2017 to 2020 (although at different nominal levels). Non-Hispanic White men also had increased overdose mortality rates for all substances between 2017 and 2020, although at lower nominal levels than Non-Hispanic Black men. Similar to treatment trends, Non-Hispanic Asian or Pacific Islander men had significantly lower overdose mortality rates for all opioid and stimulant patterns than the other racial/ethnic groups. Non-Hispanic AI/AN men had the highest methamphetamine overdose mortality rates. Like the other groups, they also experienced increased overdose rates for all opioid and stimulant combinations between 2017 and 2020. Hispanic men experienced increased overdose deaths for all opioid and stimulant combinations, with the highest relative increase in deaths involving opioids. The absolute overdose death rates were lower among Hispanic men than Non-Hispanic Black and Non-Hispanic White men.

3.5. Trends in Opioid and Stimulant Mortality for Females in the United States, 1999-2020

The rate of any opioid-related deaths increased among women of all races/ethnicities, including a steep increase from 2019 to 2020; Non-Hispanic Black women (1999: 1.5 per 100,000; 2020: 13.7 deaths per 100,000), Non-Hispanic White women (1999: 1.6 per 100,000; 2020: 14.6 per 100,000,) Non-Hispanic Asian or Pacific Islander women (1999: 0.2 per 100,000; 2020: 1.3 per 100,000), Non-Hispanic AI/AN women (1999: 2.2 per 100,000; 2020: 19.8 per 100,000), and Hispanic women (1999: 1.0 per 100,000; 2020: 5.1 per 100,000). Opioid-related deaths increased by over 600% among Non-Hispanic Black, White, and AI/AN women and over 400% among Hispanic women.

Similar to the patterns for men, Non-Hispanic Black women had the highest rates of cocaine overdose deaths, increasing from 1.7 to 7.6 per 100,000 between 1999 and 2020. Non-Hispanic Black women also experienced increased overdose rates for all opioid and stimulant combinations between 2017 and 2020. However, the rates of overdose deaths involving any opioid or any cocaine had the highest nominal rates. Non-Hispanic White women also experienced increased overdose mortality for all substance groups between 2017 and 2020; each was much lower than the nominal increase in opioid-only overdose deaths. Non-Hispanic Asian or Pacific Islander women had low overdose mortality rates for each substance type across the years, with a mild uptick in 2020. Non-Hispanic AI/AN women experienced increased overdose mortality rates involving opioids and methamphetamines. Hispanic women experienced small increases in all overdose mortality rates.

4. Discussion

This study used national surveillance data to assess opioid and stimulant-related treatment admissions and overdose deaths at the intersection of race and sex/gender. We found that overall percent increases in overdose deaths were far greater than the increases in treatment admissions. Worryingly, this suggests that the current treatment system may not be adequately addressing the ongoing overdose crisis, indicating a need for greater access to treatment and other harm reduction approaches.

Overall, opioid-related deaths far outpaced related treatment admissions; this increase in the fatality of opioids is attributed to synthetic fentanyl and its analogs, a more potent opioid that is usually ingested unintentionally though some people who use drugs prefer it (Gryczynski et al., 2019; Rhodes et al., 2019). The increase in overdose deaths is attributed, in part, to increases in the use of synthetic opioids, including inadvertently with stimulants (Ciccarone, 2021; Shearer et al., 2020). The contamination of drugs with fentanyl is a growing concern, yet the adulteration of drugs and overall poor drug quality disproportionately impact minoritized people who use drugs (PWUD) in low-resource settings, illustrated with Black people who inject drugs (PWID) being more likely to be concerned about overdosing due to fentanyl than White PWID (Jones et al., 2022; Kuehn, 2021).

We found significant variations in drug overdose deaths and treatment admissions by race/ethnicity and sex/gender. Specifically, we found that Non-Hispanic White, Black, and AI/AN men had opioid-only admissions 300%-500% greater in 2019 than in 1992; however, Hispanic men had opioid admission rates around 30% less in 2019 compared to 1999, despite a 400% increase in opioid-only related overdose deaths. Interestingly, this decrease in opioid treatment admissions was not evident in Hispanic women or any other group. These findings and nuances are missing from current discussions in this U.S. drug overdose epidemic; while there is more emphasis on drug treatment accessibility, our findings suggest that Hispanic men may have less access to treatment now compared to the early 1990s. Pinedo and colleagues (2018) found that Hispanic individuals reported more barriers to treatment than White and Black individuals who use drugs. Additionally, Hispanic individuals have been shown to have less access to medications for opioid use disorder than Non-Hispanic White individuals (Pilarinos, Bromberg, & Karamouzian, 2022; Hadland et al., 2017). While factors such as cultural adaptations to increase compatibility with Hispanic populations are known to increase treatment utilization (Amaro et al., 2006), the mechanism for understanding the reduced treatment admissions among Hispanic men is yet to be understood.

As overdose deaths involving opioids soar, naloxone is a reversal drug that is effective at saving lives (McDonald & Strang, 2016). While nearly three-quarters of PWID have been shown to have ever had naloxone, only a third currently possess the drug (Kinnard et al., 2021), although this value varies across different localities (Lipira et al., 2021; Rivera et al., 2022). Furthermore, the disparate access to these life-saving drugs among minoritized PWUD, particularly Black and Hispanic individuals, is concerning (Kinnard et al., 2021; Jones et al., 2021; Dayton et al., 2019). We showed an increase in opioid-only as well as opioid and stimulant-involved overdose deaths across all race/ethnicity and sex/gender groups. Laws promoting and even mandating the prescription of naloxone to individuals at increased risk of opioid overdoses have shown a quick expansion of naloxone (Green et al., 2020; Davis & Carr, 2017). New federal guidelines allow for an over-the-counter naloxone nasal spray, which shows promise of greater naloxone expansion (U.S. Food and Drug Administration, 2023). In addition, clinicians and public health practitioners should expand naloxone distribution to individuals who use stimulants, given the possibility of contamination with fentanyl and the risk of overdose death. Regarding treatment options, buprenorphine used to treat opioid use disorder has increased positive treatment outcomes, particularly among Black individuals who use opioids (Pro et al., 2022). Increased access may help other minoritized groups, such as Hispanic men and AI/AN women.

In addition to opioid-related treatment needs, Non-Hispanic AI/AN individuals also had marked distinctions in methamphetamine-related treatment admissions and deaths. Non-Hispanic AI/AN men had dramatically high increases in methamphetamine and opioid-implicated treatment admissions. However, these admissions were rare for Non-Hispanic Black and Asian men and low for Non-Hispanic White and Hispanic men. Similarly, methamphetamine and opioid-related treatment admissions were highest among Non-Hispanic AI/AN women, though low among women of other races/ethnicities. Corroborating the elevated methamphetamine-related treatment admissions and deaths is research by Coughlin and colleagues (2021) that found higher methamphetamine use in AI/AN communities, especially rural and low-income ones. These findings emphasize multifaceted interventions for AI/AN populations incorporating cultural strengths, increased access to rural and underserved areas, and comorbid mental health issues (Coughlin et al., 2021).

Cocaine-related deaths were a prominent cause of death among Non-Hispanic Black men in the mid-2000s; this disparity continues, as cocaine-related deaths are still approximately 250%-1000% higher for Black men than men of other races/ethnicities in 2019. Similarly, cocaine-related admissions and deaths were most common among Non-Hispanic Black women, possibly due partly to the significant reductions we observed in cocaine-only treatment admissions among Non-Hispanic Black women. Our results also support the expansion of evidence-based interventions to curb stimulant use, such as contingency management programs, particularly among racially and ethnically minoritized people who use drugs.

Culturally and multifaceted interventions for treating stimulant use may also decrease the disparities between Black and White individuals who use cocaine. Though White and Black individuals are as likely to use cocaine, Black individuals have twice the overdose mortality rate (Cano, Salas-Wright, Vaugnn, 2020). Black individuals account for 11% of those with past-year cocaine use, yet 27% of cocaine-related overdose deaths (Cano, Salas-Wright, Vaugnn, 2020). These increases may also be fueled by tainted drug supplies, such as fentanyl and analogs with cocaine (DiSilvo et al., 2021; Kuehn, 2021; Nolan et al., 2019). Nolan colleagues (2019) found that fentanyl accounted for most of the cocaine-related overdose deaths in New York. Alongside drug contamination, research shows that socio-economic characteristics (e.g., educational attainment, poverty) accounted for some but not all Black/White racial disparities in cocaine-related deaths (Cano et al., 2022). In addition, bias in healthcare has also been noted in negative outcomes for minoritized PWUD. Among patients on long-term opioid therapy for pain management, Black patients were more likely to be drug tested than White patients (Hausman et al., 2013; Gaither et al., 2018). Of those who tested positive for cocaine, providers were three times more likely to discontinue opioid treatment if the patient was Black than if the patient was White (Gaither et al., 2018).

Across all race/ethnicity groups, we found that women generally had similar temporal patterns but lower absolute levels of treatment admissions and overdose deaths. However, women are more likely to face severe consequences of substance use than men (McHugh et al., 2018). Many women who use drugs have parenting responsibilities and navigate additional stigma, shame, potential legal consequences, and economic and social disadvantages (Apsley et al., 2023; Jones et al., 2023b; Barnet et al., 2021; Frazer et al., 2019). Pregnant women and women with children are less likely to receive substance use treatment than non-pregnant women and women without children due to stigma and lack of childcare, though they may be more motivated for treatment (Asta et al., 2021; Frazer et al., 2019). Moreover, Black newborns are four to five times more likely to be referred to Child Protective Services than White newborns though Black and White pregnant women have similar rates of drug use (Roberts et al., 2015; Roberts & Nuru-Jeter, 2012). This disparity persists even as Black pregnant women who use drugs enter treatment at a higher-than-expected level and when hospitals develop universal screening protocols in failed attempts to remove these racial disparities (Roberts et al., 2015; Roberts & Nuru-Jeter, 2012). These findings illustrate the intersection of racism, sexism, and addiction and the need to incorporate the varying levels of consideration in intervention and policies on SUD.

Overall, increases in drug overdose deaths among minoritized populations (women, racial/ethnic minorities) may illustrate the complex interplay of the social determinants of health and substance use disorders. Minoritized groups often face social disadvantages (e.g., poverty and homelessness) along with psychiatric (e.g., trauma and depression) challenges that complicate substance use, drug treatment, and the likelihood of fatal and nonfatal overdoses (Meyer et al., 2019; Tighe, 2014). In addition, high rates of victimization and homelessness, 85% and 40%, respectively, have been documented among women who use drugs and minoritized individuals, highlighting the need for trauma-informed care (Frazer et al., 2019; Tighe, 2014). Regional differences in the availability and access to comprehensive substance use treatment may prevent women and racially/ethnically minoritized individuals from receiving necessary care (Coughlin et al., 2021; Frazer et al., 2019).

Our study also has several limitations to note. First, in CDC WONDER data, we can identify multiple substances (e.g., opioids and cocaine) but not single substances with the exclusion of all other drugs. For example, we cannot explicitly identify only opioids but can identify overdose deaths with opioids, with or without other substances. Second, there may be misreporting for both treatment and overdose death data. Especially early in the rise of synthetic opioids, stimulant users may be unaware drugs may contain synthetic opioids.

Similarly, coroners may have imperfectly tested for synthetic opioids, although this was more likely at the beginning of the synthetic opioid rise. In addition, we did not distinguish types of substance use treatment received and age differences in overdose mortality, which has been documented, particularly during the COVID-19 pandemic (Jones et al., 2023a). One reason for the documented age differences is that deaths necessarily preclude treatment. Yet, we emphasize that while treatment and overdose mortality data can have different age distributions, it does not impact nominal differences, which are important surveillance warning signs to document. Lastly, data for TEDS admissions and CDC overdose deaths ended in 2019 and 2020, respectively, as these data were publicly available during this study. These do not address the most current years of this drug overdose epidemic.

5. Conclusion

Our study findings illustrate distinctive and heterogeneous patterns in the drivers of the increases and within-substance use causes of death. We found steep increases in opioid and stimulant drug treatment admissions and overdose deaths among Non-Hispanic White, Black, AI/AN men and women. Yet, a major policy concern is that increases in drug treatment admissions were lower than increases in overdose deaths, suggesting that current treatment availability may be inadequate to address the overdose crisis. At the intersection of race and sex, groups of minoritized women (Non-Hispanic AI/AN and Non-Hispanic Black women) faced much higher admissions and overdose deaths than other women. While the opioid epidemic has garnered much attention, there seems to be a need to uncover the complex patterns underlying both treatment use and mortality; such analyses may do well in incorporating an intersectionality approach, given that patterns differ at the intersection of sex and race/ethnicity in the United States. In particular, we observed far more similar treatment and overdose mortality patterns within each racial and ethnic group than across sex/gender —e.g., temporal patterns for Non-Hispanic Black women look more like patterns for Non-Hispanic Black men than for other female racial/ethnic groups. However, treatment and overdose rates tended to be higher for men than women. The results highlight the critical need to tailor treatment and harm reduction strategies for different racial and ethnic groups. Data on treatment options for stimulant use and their effectiveness, along with SUD treatment completion rates by race/ethnicity and sex/gender, need further examination.

Supplementary Material

1

Figure 3:

Figure 3:

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Trends in Opioid and Stimulant Mortality for Males in the United States, 1999-2020

Highlights.

  • We evaluate race/sex differences in opioid and stimulant treatment admissions and deaths

  • We use data from TEDS-A and CDC WONDER to identify treatment admissions and overdose deaths

  • We found significant variations in drug treatment admissions and overdose deaths by race/sex

  • Variations by race/sex suggest interventions developed with an intersectionality lens are needed

Funding Source:

K01DA051715 (P.I.: Jones)

Footnotes

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Conflict of Interest: No conflict declared

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