Widening Racial Disparities in the U.S. Overdose Epidemic

Abstract

Introduction:

More Americans died in 2021 from drug overdose than from vehicle accidents and firearms combined. Unlike earlier phases, the current epidemic is marked by its disproportionate impact on communities of color. This report investigates regional and substancespecific variations in racial disparities to generate possible insights into the various forces shaping these trends.

Methods:

This report used data from 1999 to 2022 on opioid-related overdose deaths from the Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research database. Racial disparities at the national, state, and substance levels were compared to describe heterogeneities in disparities trends. Data were analyzed in 2024.

Results:

Overall age-adjusted overdose mortality in the U.S. increased from 6.2 to 32.7 deaths per 100,000 between 1999 and 2022. In this same time period, mortality has increased most rapidly in Black, Native, and Hispanic/Latino Americans at 249.3%, 166.3%, and 171.8%, respectively. Disparities with White populations vary regionally. The upper Midwest (i.e., Minnesota, Wisconsin) and Washington state rank highest in excessive Native overdose death; the upper Midwest and Washington, DC rank highest as Black overdose deaths. In terms of substances, deaths from polyuse of methamphetamines and opioids have been highest among Native Americans over time, whereas deaths from cocaine and opioids disproportionately impact Black Americans.

Conclusions:

The opioid epidemic continues to expand, with particularly rapid acceleration in racially minoritized communities. The growing role of stimulants in opioid overdose deaths is a racialized phenomenon disproportionately impacting Black and Native Americans. Wide variation in state-level disparities suggest that structural racism impacts health in regionally specific ways, highlighting the need for regional solutions.

INTRODUCTION

According to data from the National Vital Statistics System, more Americans died in 2021 from drug overdose than from vehicle accidents and firearms combined. The current death toll is nearly 3 times higher than it was in 2011 when the U.S. Centers for Disease Control and Prevention (CDC) declared drug doses as an epidemic.¹ The U.S. epidemic is also unique on the global scale, with overdose mortality rates 20 times that of the global average.²

Rates of overdose mortality are climbing in nearly every social and demographic group in the U.S. but nowhere faster than in communities of color. The earliest wave of overdose deaths beginning in the early 2000s was concentrated in lower-income White communities inundated with easily accessible prescription opioids.³ More recent phases of the opioid epidemic have been marked by the proliferation of illicit fentanyl, a result some attribute to the Iron Law of Prohibition in which supply-side interventions (e.g., the Prescription Drug Monitoring Program, abuse-deterrent reformulations) pushed the illicit drug supply to favor increasingly compact—and therefore more potent—substitutes.⁴ Specifically, in the absence of a concomitant scale-up of addiction treatment services, these interventions served only to cut off access in people already dependent on opioids, forcing many to turn to black market alternatives, including heroin. As heroin-related overdoses rose, so too did federal drug interdiction efforts (e.g., drug seizures along the U.S.–Mexico border) creating the conditions that encouraged international cartels to transition to more potent opioid analogs such as fentanyl.⁵ The market shift from heroin to fentanyl has had a particularly profound impact on communities of color, resulting in the recent reversal of the racial gradient in which Black mortality rates overtook those of Whites for the first time in decades.⁶ The relative vulnerability of people of color to supply shocks such as fentanyl has been variously attributed to these communities’ limited access to overdose prevention tools (i.e., naloxone) as well as to the medical bias that has historically limited these communities’ access to alternative—and comparatively safer—drug sources such as the prescription market.^7,8

Several reports have called attention to these widening racial/ethnic gaps, citing drivers such as historical trauma, structural racism, and the exacerbation of social inequities by the coronavirus disease 2019 (COVID-19) pandemic.^9-14 Many have also noted that rising overdose deaths from the combined use of stimulants and opioids—commonly referred to in the opioid literature simply as polyuse—disproportionately impact communities of color.^14-17 These analyses collectively highlight how intersections of key social or environmental dimensions such as geography, age, or substances have shaped these current dynamics. However, whether because the data used are restricted to the pre–COVID-19 pandemic era,^14,17 to individual states,^15,16 or to only certain racial/ethnic groups,^14-17 reports to date leave unanswered key questions about the scale and nature of racial/ethnic disparities.

This report carries out a national-level, descriptive analysis to generate novel insights into the various forces shaping these trends. It also addresses previous knowledge gaps using data (1) from a longer time period; (2) that span the COVID-19 pandemic; and (3) that include all available racial/ethnic group data, including on Native Americans, the most commonly excluded group despite being one of the most heavily impacted.¹⁸

METHODS

Study Sample

Relevant deaths occurring between 1999 and 2022 were identified using the CDC’s Wide-Ranging Online Data for Epidemiologic Research (WONDER) database.

Measures

This database classifies reported deaths according to ICD-10. Although all states require death certificates to identify substances that may have contributed to a death as the underlying cause, this analysis included any deaths in which drug poisoning (i.e., overdose) was listed as an underlying cause and opioids as a multiple cause of death. The codes specific to underlying causes of death, including those categorized as unintentional, suicide, homicide, or undetermined drug poisonings, consisted of the following codes: X40-X44, X60-X64, X85, and Y10–Y14. To ensure that the overdose death was opioid related, the following codes were also included: opium (T40.0); heroin (T40.1); other natural and semisynthetic opioids such as codeine, morphine, hydrocodone, or oxycodone (T40.2); methadone (T40.3); other synthetic narcotics such as tramadol, fentanyl, and fentanyl derivatives (T40.4); and other and unspecified narcotics (T40.6). The secondary analyses on couse of stimulants such as cocaine and methamphetamines were considered by additionally including their respective codes: T40.5 for cocaine and T43.6 for methamphetamines. The latter code includes many types of psychostimulants (e.g., caffeine, MDMA), but studies show that within overdose deaths including this code, methamphetamines are the most commonly implicated stimulant.¹⁹

All deaths were classified into race/ethnicity subgroups using available categories provided by in the WONDER database. The categories used in this analysis were dictated by classifications available in the 1999 −2020 subset of data, which includes American Indian or Alaska Native (AIAN), Asian or Pacific Islander (API), Black or African American, and White. A fifth race/ethnicity category was formed using information on Hispanic ethnicity by categorizing any individual indicating Hispanic as their ethnicity as Hispanic/Latino, regardless of their concurrent choice of race. Individuals indicating not Hispanic as their ethnicity were categorized according to their racial category, and those indicating not stated as their ethnicity were excluded because this group lacks the necessary population size estimates to calculate age-adjusted mortality. Beginning in 2021, CDC WONDER began using a new 6-category racial/ethnic classification system: AIAN, Asian, Black or African American (referred to as Black in the remaining parts of this paper), more than 1 race, Native Hawaiian or other Pacific Islander, and White. To harmonize race categories before and after 2021, the Asian and Native Hawaiian or other Pacific Islander categories were collapsed into a single API group, and those classified as more than 1 race were excluded. Exclusion of those classified as more than 1 race from the 2021 and 2022 data resulted in the dropping of 1,631 (1.4%) and 1,799 (1.6%) deaths and 9,790,211 (2.9%) and 10,070,657 (3.0%) of the overall population, respectively.

Temporal dimensions of the overdose epidemic were considered using all available years of validated data (1999–2022). Spatial dimensions were considered using annual, state-specific data on deaths and population estimates provided through CDC WONDER. All temporal and spatial dimensions were stratified by the race/ethnicity categories provided in the database.

Statistical Analysis

Age-adjusted mortality was calculated using the U.S. year 2000 standard population and were expressed as the number of deaths per 100,000 people. Subgroup-specific mortality rate estimates were calculated by restricting data to a given year, state, or racial/ethnic group. Mortality rate differences were calculated as differences in age-adjusted mortality rates for the 2 racial/ethnic groups with the highest recent overdose mortality rates —that is, Black and AIAN—compared with the White population. In accordance with WONDER data-use restrictions, mortality rates were not calculated in years when there were <20 deaths in any given subgroup.

Given the complex interplay between race and ethnicity in the U.S. context, an additional comparison of mortality rates across Hispanic versus non-Hispanic ethnicity were conducted within each racial category (AIAN, API, Black, White). Owing to the small numbers of deaths in certain group and years—particularly for AIAN populations—this subanalysis pooled deaths across the most recent 5 years of data (2018–2022) to avoid the data-suppression limitation. Crude rates were used for this subanalysis because the 2 different racial classification systems before and after 2018 precluded calculation of age-adjusted mortality.

As an analysis of deidentified, publicly available data, the IRB of the University of Minnesota determined that this analysis did not constitute human subjects research. It was therefore exempted from review, and informed consent was waived. Data were analyzed in 2024.

RESULTS

Since 1999, overall opioid overdose mortality rates have increased over 4-fold from 6.2 to 32.7 deaths per 100,000, corresponding to an annual increase of 7.85% (Figure 1). The steady upward trajectory at the national level has been largely mirrored across all racial/ethnic subgroups. The one exception is the temporary decline in 2018, which was only reflected in the White population, a pattern that underscores the outsized role of this group in explaining national trends. Patterns vary greatly by race/ethnicity, with Native and White Americans experiencing rates consistently above the national average and API and Hispanic/Latino Americans experiencing below-average rates. Notably, Black mortality rates remained relatively flat throughout the 2000s until a rapid increase beginning in 2017. In 2019, it surpassed that of White Americans for the first time since 2001. The same, sudden jump in mortality rates beginning in the 2010s is apparent across all other non-White groups. Rates in the most recent phase (2015–2022) have climbed most rapidly in Black Americans (249.3% increase), Native Americans (166.3%), and Hispanic/Latino Americans (171.8%). Increases in this same period for API and White Americans have been relatively lower at 87.1% and 57.1%, respectively.

Figure 1.

Annual age-adjusted and race-stratified opioid-involved mortality with 95% CIs in the U.S. between 1999 and 2022.

Data are from the Centers for Disease Control and Prevention’s WONDER database.

WONDER, Wide-Ranging Online Data for Epidemiologic Research.

Figure 2 illustrates state-specific differences in 2022 mortality rates between White and Native Americans (Figure 2A) and White and Black Americans (Figure 2B). Mortality rates—and therefore their differences—are only shown for the subset of states in which at least 20 deaths occurred in each subgroup in 2022. For Native/White differences, Minnesota had the highest mortality rate difference, with 237.4 more Native deaths per 100,000 people (95% CI=198.6, 276.2), followed by Wisconsin (111 more deaths [95% CI=78.6, 143.4]) and Washington (96.6 more deaths [95% CI=75.0, 122.2]) state. Black–White disparities were greatest in Washington, DC, with 106.8 more Black deaths per 100,000 (95% CI=92.9, 120.7), followed by Wisconsin (75.6 more deaths [95% CI=65.5, 85.7]) and Minnesota (56.8 more deaths [95% CI=48.7, 64.9]).

Figure 2.

Absolute differences in opioid-involved mortality rates in 2022 between American Indian/Alaskan Native and White and between Black and White populations. (A) American Indian/Alaskan Native and White. (B) Black and White populations.

Data are from the Centers for Disease Control and Prevention’s WONDER database. States are missing if <20 deaths were reported in any given subgroup, per CDC WONDER reporting guidelines.

CDC, Centers for Disease Control and Prevention; WONDER, Wide-Ranging Online Data for Epidemiologic Research.

Figure 3 illustrates the patterns in polyuse of opioids and stimulants through race/ethnicity stratification of opioid-related mortality in which methamphetamines (Figure 3A) or cocaine (Figure 3B) were also involved. Deaths involving methamphetamine were most prevalent in Native Americans among whom mortality rates began to increase more rapidly in 2010, reaching 31.9 deaths per 100,000 by 2022. The next most impacted group were White Americans whose 2022 mortality rate was 12.8 deaths per 100,000. Black Americans were the most heavily impacted by opioid overdose deaths involving cocaine, whose mortality rates were consistently higher than those of other racial/ethnic groups and who also experienced a faster increase beginning in 2015.

Figure 3.

Annual age-adjusted and race-stratified opioid-involved mortality with 95% CIs from 1999 to 2022 in which either methamphetamines or cocaine were also involved. (A) methamphetamines. (B) cocaine.

Data are from the Centers for Disease Control and Prevention’s WONDER database.

WONDER, Wide-Ranging Online Data for Epidemiologic Research.

A final comparison of crude mortality rates across Hispanic and non-Hispanic ethnicities within the 4 racial categories provided by CDC WONDER showed marked differences by Hispanic ethnicity (Figure 4). Most notable was the far higher crude mortality in those who did not identify as Hispanic than in those who did among the following racial groups: AIAN (44.4 [95% CI=43.2, 45.6] vs 5.5 [95% CI=5.0, 6.0] deaths per 100,000), Black (34.8 [95% CI=34.6, 35.1] vs 11 [95% CI=10.6, 11.7] deaths per 100,000), and White (31.5 [95% CI=31.4, 31.6] vs 18.2 [95% CI=18.0, 18.3] deaths per 100,000).

Figure 4.

Opioid-involved mortality rates with each racial group stratified by Hispanic (lighter shades) and non-Hispanic (darker shades) ethnicity.

Deaths are pooled across 2017 to 2022, hence the use of crude (versus age-adjusted) mortality rates. Data are from the Centers for Disease Control and Prevention’s WONDER database.

WONDER, Wide-Ranging Online Data for Epidemiologic Research.

DISCUSSION

The opioid epidemic has continued to expand since its initial recognition as a national epidemic in 2011, since when rates have increased by 147.7%. The current phase, which began in 2015, is defined by the widening of racial/ethnic disparities, with the most notable increases in Black, Hispanic/Latino, and Native communities. Rates in API and White Americans have also increased, although to a lesser extent. Also notable is that the temporary decline in national mortality rates in 2018 was largely a White phenomenon because this was the only racial group in which the same pattern was observed. Finally, accelerating overdose mortality rates experienced by nearly all groups appear to largely predate the COVID-19 pandemic, highlighting the deep-rooted nature of its many determinants that predate the pandemic.²⁰ More formal estimations of the magnitude of the impact of COVID-19 on the opioid epidemic will require adequate data from the postpandemic era.

Primary findings from this descriptive analysis align with existing reports of rising deaths due to polyuse as well as growing racial/ethnic disparities, 2 trends that both predate the COVID-19 pandemic.^14,15,17 Many of these reports note the rapid rise in overdose mortality rates in non-Hispanic Black communities,^14-16,20 but only 1 includes Native American groups in their racial/ethnic stratifications and which does not consider substance-specific patternings.⁹

In terms of geography, this analysis identified the upper Midwest (Minnesota, Wisconsin) and Washington state as regions of excessive Native overdose death relative to White deaths (Figure 2). Past reports on the topic have identified the same hotspots,^21,22 with Tipps et al.²² in particular singling out the counties containing Seattle and Minneapolis as the 2 hardest hit in the country. These authors note that the proximity of multiple tribal reservations to the large metropolis of Seattle and Minneapolis may be a driver of regional migration to urban areas where there is easier access to more potent opioids. A full understanding of Native overdose risk will require more insights into both metropolitan and reservation environments.²³ For example, lack of harmreduction services in reservation settings (e.g., naloxone, medications for opioid use disorder) is greatly shaped by chronic underfunding of the Indian Health Service,²⁴ whereas in urban settings, where 70% of Native Americans live, barriers stem from a complex and poorly coordinated system of care across Indian Health Service, tribal, and state health systems.^25,26

Substance-specific analyses in this report highlight the disproportionate burden of overdose from polyuse of methamphetamines and opioids in the Native community (Figure 3A). This is consistent with past reports on historically high rates of use and death from methamphetamines in Native communities,²⁷ although its hypothesized determinants—for example, underfunded tribal police forces, limited addiction treatment options in tribal health centers^28,29—are unique to reservation settings, underscoring the need for more research on the urban context of stimulant use in this community. Furthermore, research on methamphetamines in the Native community indicates that its use has remained flat or has declined at a time of rising mortality from polyuse of this drug and opioids.²⁹ This suggests that substance-use patterns do not fully explain recent trends, highlighting the need for more research on these patterns to inform prevention strategies, including education for those using stimulants about the risks of fentanyl.³⁰

Regarding Black/White regional disparities, this analysis identified Washington, DC, and the upper Midwest (Wisconsin, Minnesota) as epicenters of excessive Black overdose death. Other reports noting highlighted magnitude of Black/White disparities in the nation’s capital have noted the problematic local response to the rise of fentanyl,^31,32 a claim in need of more research. Disparities observed in the upper Midwest are notable as the product of high Black overdose mortality and unusually low White overdose mortality. Midwestern scholars have long noted similar patterns in other spheres, including income or education, suggesting that many regional disparities are best understood as results of unusually generous yet racially selective state investment in social services.³³ This speaks both to the promise of public welfare programs and to the long-lasting harms of practices that exclude communities of color (e.g., redlining, racial covenants).

Regarding substance-specific disparities, this analysis found that deaths from polyuse of cocaine and opioids disproportionately impact Black Americans, a finding consistent with a recent report on polyuse trends.³⁴ As with the Native community, this phenomenon may stem from some combination of intentional polyuse as well as inadvertent fentanyl exposure due to contamination of the stimulant supply, on which further research is needed. Unreliable access to naloxone and other harm-reduction services in many Black communities drive some of the observed disparities.³⁵ However, closing these gaps will require programs that meaningfully address historic opposition to harm reduction in many medically underserved communities where such interventions have often been perceived as cheap substitute(s) for rehabilitation rather than as legitimate health care.^36,37

Although overdose mortality rates among Hispanic/Latino Americans remain well below the national average, rapidly rising rates in recent years highlight the need for more monitoring and prevention in this population. As with other minoritized racial/ethnic groups, shifting trends in polyuse behaviors, fentanyl contamination of the illicit drug supply, or poor access to overdose prevention tools all likely play a role, but such research will need to carefully consider the group’s extensive diversity in terms of demographics, nativity, and shared culture.³⁸

Limitations

Reported findings must be interpreted in light of several key limitations. Racial misclassification on death certificates is a widely recognized issue, particularly for indigenous decedents among whom racial misclassification by nontribal authorities is common. Past studies have found that the sensitivity of racial classifications for Native communities can be as low as 38%,³⁹ an issue contributing to underestimation of outcomes ranging from life expectancy⁴⁰ to HIV infection.⁴¹ Past analyses of racial misclassification’s impact on estimates of fatal opioid overdose in Native communities suggest that trends presented in this study may underestimate true rates by up to 42.5%,^22,42 although the lack of a nationallevel tribal registry precludes direct estimation of its impact on presented data. Second, deaths in 2021 and 2022 among those whose race was classified as more than 1 race were excluded, a necessary accommodation for data harmonization but which likely underestimates mortality rates in groups who would otherwise have been classified as non-White under the earlier classification system. Third, the designation of White Americans as the ref category seemingly disregards critiques that such methods normalize dominant groups while implying inferiority of minoritized groups.⁴³ However, much of the harms of such practices arise from interpretations of results that attribute health outcomes to individuallevel factors (e.g., lifestyle, genetics) without considering social-level determinants. This analysis considers racial/ethnic group comparisons for the explicit purpose of identifying social determinants of inequity—notably, within an epidemic in which White race has not always been protective. Finally, the challenge of data suppression for lower death counts limits the ability to conduct more granular analyses (e.g., county-level spatial units), a decision that limits insights into temporal trends in comparisons of Hispanic with non-Hispanic race–stratified mortality rates (Figure 4).

CONCLUSIONS

The determinants of racial disparities in the U.S. overdose epidemic are complex and span many domains of life; so too must be the response. Hybrid addiction services that blend biomedical interventions, harm-reduction services, and behavioral interventions have shown great promise,⁴⁴ but narrowing the racial gaps in overdose mortality will require specialized efforts that incorporates input from a community members to ensure that such services are genuinely accessible and acceptable to target communities.⁴⁵ The centrality of socioeconomic determinants also underscores the need for strategies tackling the link between poverty and addiction,³ particularly those correcting the historical overallocation of resources to majority White communities (e. g., reparation initiatives in local government^46-48 and educational settings).⁴⁹ Finally, narrowing racial disparities will require close partnerships with communities, many who have understandable reservations about working with medical researchers. Community-based organizations are vital to this response not only for their effectiveness in improving community health⁵⁰ but also for their role in bridging the divide between historically marginalized communities and institutions that have violated their trust.