Comparison of persons who died of drug overdoses with and without evidence of hepatitis C, United States, 2019–2024

Abstract

Background:

Injection drug use is the most common risk factor for hepatitis C virus (HCV) infection. Despite decreases in injection drug use among overdose decedents during 2020–2022, reported cases of newly-acquired hepatitis C remained relatively stable. This analysis compares sociodemographic characteristics and circumstances among overdose decedents with and without evidence of hepatitis C to inform prevention.

Methods:

CDC’s State Unintentional Drug Overdose Reporting System (SUDORS) collects data on unintentional and undetermined intent drug overdose deaths, including HCV infection information. Percentages of overdose deaths during July 2019–December 2024 with sociodemographic characteristics, drugs involved, and circumstances were calculated by hepatitis C evidence (48 jurisdictions). To assess trends, the percentage of overdose deaths with hepatitis C evidence was calculated by 6-month period from July 2019 to December 2024 (30 consistently reporting jurisdictions).

Results:

Among 328,754 decedents, compared to those without hepatitis C evidence (94.6%), those with hepatitis C evidence (5.4%) more often were aged ≥ 55 years (36.0% vs. 24.7%) and non-Hispanic White (75.9% vs. 63.9%), and had ≥ 1 recent touchpoint or potential intervention opportunity (e.g., mental health treatment, nonfatal overdose; 40.3% vs. 23.9%). The percentage with hepatitis C evidence increased from 5.3% during July–December 2019 to 7.2% during July–December 2024.

Conclusions:

Implementing community-based services to prevent infectious disease spread and overdose, accessible hepatitis C testing, linkage to substance use disorder treatment and curative hepatitis C treatment, and robust public health surveillance to identify populations for tailored prevention efforts might help address hepatitis C and drug use epidemics.

1. Introduction

Drug overdoses and hepatitis C are at epidemic levels in the United States (Centers for Disease Control and Prevention, 2025; Hall et al., 2025). During 2024, 79,384 persons died of a drug overdose (Centers for Disease Control and Prevention, 2025; Garnett and Miniño, 2026). Hepatitis C, a liver disease caused by the hepatitis C virus (HCV), can result in substantial morbidity and mortality if left untreated (Moorman et al., 2018). More than 2.4 million adults are estimated to have current HCV infection in the U.S., making it the most common bloodborne infection in the country (Hall et al., 2025). During 2023, there were an estimated 69,000 new HCV infections and over 11,000 hepatitis C-related deaths reported (Centers for Disease Control and Prevention, 2025). Drug overdose and hepatitis C have shared risk factors; in the U.S., the most common risk factor for HCV infection is injection drug use (Centers for Disease Control and Prevention, 2025; Shepard et al., 2005), and numerous outbreaks among persons who inject drugs (PWID) have been investigated (Centers for Disease Control and Prevention, 2018; Hudson et al., 2023; Ramachandran et al., 2018). Despite decreases in the percentage of persons who died from overdoses with evidence of injection drug use from January–June 2020 to July–December 2022 (Tanz et al., 2024), the number of reported cases of newly acquired hepatitis C remained relatively stable from 2021 to 2023 (Centers for Disease Control and Prevention, 2025). As drug overdoses and HCV infection persist in the U.S., and because there is no vaccine to prevent hepatitis C, prevention efforts must focus on reducing high risk behaviors like injection drug use.

Hepatitis C became a nationally notifiable condition in the United States in 1994 (Jiles et al., 2025). The Centers for Disease Control and Prevention (CDC) conducts routine surveillance on hepatitis C through the National Notifiable Diseases Surveillance System (Centers for Disease Control and Prevention, 2024); however, 2022 was the first full year that federal funding to conduct comprehensive surveillance for hepatitis C was available nationwide (Centers for Disease Control and Prevention, 2024). Because many jurisdictions are still building their hepatitis C surveillance capacity, limited information about risk factors is available in routine surveillance data. CDC’s State Unintentional Drug Overdose Reporting System (SUDORS) collects in depth information on persons who died of drug overdoses, including whether they had evidence of hepatitis C and can therefore provide detailed information on a subset of persons with hepatitis C (Centers for Disease Control and Prevention, 2025). SUDORS data complement existing information on risk factors for acquiring HCV infection and prevention of related health outcomes by identifying opportunities to prevent fatal overdose, a co-occurring severe outcome, among persons with hepatitis C. The goal of this analysis was to utilize SUDORS data to compare sociodemographic characteristics and circumstances among persons who died of overdoses with and without evidence of hepatitis C to inform prevention efforts for the hepatitis C and drug overdose syndemic.

2. Methods

2.1. Data source

SUDORS collects data on unintentional and undetermined intent drug overdose deaths from 49 states and the District of Columbia (DC) as part of the Overdose Data to Action in States cooperative agreement (Centers for Disease Control and Prevention, 2024). Data in SUDORS are collected from three required data sources: death certificates, medical examiner or coroner (ME/C) reports, and postmortem toxicology reports. Together, these sources provide comprehensive information on sociodemographic characteristics of persons who died of a drug overdose, circumstances surrounding the death (e.g., scene evidence), all drugs detected and involved in the death, and the decedent’s social and medical history and were used to conduct this cross-sectional study.

2.2. Evidence of hepatitis C

SUDORS contains a variable that captures whether there was evidence (i.e., in one of the source documents, such as ME/C reports) that the decedent had hepatitis C either at the time of the overdose or in the past. Additionally, decedents were considered to have evidence of hepatitis C if an International Classification of Disease 10^th revision (ICD–10) code consistent with hepatitis C (acute hepatitis C: B17.1; chronic viral hepatitis C: B18.2; unspecified viral hepatitis C: B19.2) was present in a multiple cause of death field on the decedent’s death certificate. Lastly, the literal cause of death text fields on the death certificate were searched for terms that could indicate hepatitis C (“hepatit”, “hepc”, “hep c”, “hcv”, “jaundice”). Overdose deaths with one of these terms were then reviewed to confirm evidence of hepatitis C. A binary variable was created combining data from the hepatitis C variable, ICD–10 codes, and text search of cause of death fields to indicate if the decedent had evidence of hepatitis C.

2.3. Sociodemographic information

Sociodemographic variables included age, sex, race and ethnicity, highest attained educational degree, U.S. Census Bureau divisions, and urban-rural status. Age was categorized as < 15 years, 15–24, 25–34, 35–44, 45–54, 55–64, and ≥ 65 and race and ethnicity was categorized as non-Hispanic American Indian/Alaska Native, non-Hispanic Asian, non-Hispanic Black, non-Hispanic Native Hawaiian or Pacific Islander, non-Hispanic White, non-Hispanic multiple races, and Hispanic. Highest level of attained education was categorized into three categories (less than high school, high school degree or GED, and more than high school). Overdose deaths were classified as occurring in urban or rural counties based on the location where the overdose occurred. SUDORS data on the state and county of the overdose were linked to the National Center for Health Statistics 2023 Urban-Rural Classification Scheme (Centers for Disease Control and Prevention, 2024). Large central metropolitan counties were considered urban; large fringe metropolitan, medium metropolitan, and small metropolitan were considered suburban; non-metropolitan counties were considered rural.

2.4. Toxicology information

Data on drugs involved (i.e., listed as causing or contributing to death) in overdose deaths were abstracted from death certificates and postmortem toxicology reports. Deaths were classified into non-mutually exclusive categories of drug involvement: any opioids, illegally-made fentanyls (IMFs), heroin, prescription opioids, any stimulants, cocaine, and methamphetamine. Fentanyl was classified as illegally-made based on toxicology, scene, and witness evidence (O'Donnell et al., 2022). Additionally, overdose deaths were classified into four mutually exclusive categories of drug involvement: opioids and stimulants, opioids and no stimulants, stimulants and no opioids, and neither opioids nor stimulants.

2.5. Circumstance information

Information on circumstances surrounding overdose deaths included experiencing homelessness or housing instability at the time of the overdose, being in custody at the time of the overdose, being recently released from an institutional setting (within one month of death), current or past mental health or substance use disorders (SUDs) including treatment, history of drug use and overdoses, recent emergency department (ED) visits (including visits both within one year and within one month of death), location of the fatal overdose, routes of drug use (i.e., ingestion, injection, smoking, snorting), and response to the overdose (e.g., naloxone administered). A composite variable denoting recent touchpoints or potential opportunities for intervention was created and included release from an institutional setting within one month of death, treatment for substance use or mental health disorders within two months of death, emergency department or urgent care visit within one month of death, and nonfatal overdose within one month of death.

2.6. Inclusion criteria

For analyses of sociodemographic, toxicology and circumstance data, jurisdictions were required to report at least 75% of overdose deaths that occurred in their jurisdiction and abstract medical examiner and coroner reports for at least 75% of deaths that occurred in at least one 6-month period during July 2019–December 2024; 47 states and DC (48 jurisdictions) were included. Thirty jurisdictions reported data for the full timeframe and 18 reported data for at least one 6-month period. To be included in trend analyses, jurisdictions were required to report at least 75% of overdose deaths that occurred in their jurisdiction and abstract medical examiner and coroner reports for at least 75% of deaths that occurred during July 2019–December 2024; 29 states and DC (30 jurisdictions) were included. All analyses were restricted to overdose deaths with information on circumstances surrounding the overdose death to ensure the possibility of capturing evidence of hepatitis C.

2.7. Statistical analysis

Numbers and percentages of overdose deaths that occurred during July 2019–December 2024 with specific sociodemographic characteristics, drugs involved, and circumstances were calculated by evidence of hepatitis C. Pearson’s chi-square and Fisher’s exact tests were used to compare characteristics of decedents with and without evidence of hepatitis C. Two-sided P-value < 0.05 was considered statistically significant. For variables with more than two categories, Pearson chi-square and Fisher’s exact tests were used to identify statistically significant differences between binary subcategories of the main variable by evidence of hepatitis C. All differences highlighted in the text reflect statistically significant differences. The number and percentage of overdose deaths with evidence of hepatitis C were also calculated by 6-month period from July 2019 to December 2024. Additionally, the percentage of overdose deaths with evidence of each route of drug use (i. e., ingestion, injection, smoking, and snorting) was calculated by evidence of hepatitis C for each 6-month period from July 2019 to December 2024. For trend analyses, Cochran-Armitage tests were used to assess whether there was a linear relationship between 6-month period and the proportion with evidence hepatitis C or with each route of drug use. Because decedents with evidence of hepatitis C might have better documentation of circumstances surrounding the overdose, a sensitivity analysis was conducted comparing circumstances surrounding the fatal overdose for those with evidence of hepatitis C to those without hepatitis C but with a medical history of heart disease, a group which is also likely to have better documentation. Another sensitivity analysis was conducted restricting sociodemographic, toxicology, and circumstance analyses to the same jurisdictions as were included in the trend analysis. Analyses were performed using SAS software (version 9.4; SAS Institute, Cary, NC).

This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy (CFR).

3. Results

3.1. Overall prevalence and sociodemographic characteristics

During July 2019–December 2024, 328,754 overdose deaths with data available on circumstances were reported by 47 states and DC (Table 1). Evidence of hepatitis C was reported for 5.4% (n = 17,668) of decedents over the timeframe. The majority of decedents with evidence of hepatitis C were aged 35–64 years (72.1%), male (67.4%), non-Hispanic white (75.9%), had a high school education or less (81.3%), and lived in suburban areas (55.0%). The most notable differences in demographics across groups were that those with evidence of hepatitis C were more often aged 55 years and older (36.0% vs. 24.7%) and non-Hispanic White (75.9% vs. 63.9%) than those without evidence of hepatitis C.

Table 1.

Sociodemographic characteristics of persons who died of a drug overdose stratified by evidence of hepatitis C^a — 47 states and the District of Columbia,^b July 2019–December 2024.

	Evidence of hepatitis C 17,668 (5.4%)	No evidence of hepatitis C 311,086 (94.6%)
	n (%)	n (%)	P-valuec
Age group (years) d			< 0.0001
< 15	5 (<0.1)	830 (0.3)
15–24	217 (1.2)	18,821 (6.1)
25–34	2843 (16.1)	67,312 (21.6)
35–44	4471 (25.3)	81,014 (26.0)
45–54	3763 (21.3)	66,285 (21.3)
55–64	4508 (25.5)	58,016 (18.7)
65+	1861 (10.5)	18,778 (6.0)
Sex			< 0.0001
Male	11,916 (67.4)	220,829 (71.0)
Female	5751 (32.6)	90,251 (29.0)
Race and ethnicity			< 0.0001
American Indian/Alaska Native, non-Hispanic	407 (2.3)	4960 (1.6)
Asian, non-Hispanic	39 (0.2)	2304 (0.7)
Black, non-Hispanic	2172 (12.4)	67,881 (22.0)
Hispanic	1390 (7.9)	32,297 (10.5)
Multi-race, non-Hispanic	196 (1.1)	3538 (1.1)
Native Hawaiian or other Pacific Islander, non-Hispanic	10 (0.1)	390 (0.1)
White, non-Hispanic	13,288 (75.9)	197,265 (63.9)
Education d			< 0.0001
Less than high school	4274 (25.8)	66,472 (22.4)
High school graduate or GED	9200 (55.5)	156,178 (52.5)
Some college, no degree	1950 (11.8)	40,552 (13.6)
College degree or higher	1141 (6.9)	34,049 (11.5)
Urbanization d,e,f	n = 17,459	n = 307,352	< 0.001
Rural	1981 (11.6)	36,310 (12.0)
Suburban	9409 (55.0)	160,636 (53.0)
Urban	5716 (33.4)	106,185 (35.0)

Abbreviations: GED = General Education Development; ICD–10 = International Classification of Disease 10th Revision; SUDORS = State Unintentional Drug Overdose Reporting System.

^aDecedents were considered to have evidence of hepatitis C if one of the three following criteria were met: the hepatitis C checkbox within the SUDORS web-based system was endorsed; an ICD–10 code consistent with hepatitis C (B17.1, B18.2, B19.2) was present in a multiple cause of death field on the decedent's death certificate; or there was evidence of hepatitis C in the literal cause of death text fields on the decedent's death certificate.

^bTo be included, jurisdictions were required to report ≥ 75% of overdose deaths that occurred in their jurisdiction and abstract medical examiner and coroner reports for ≥ 75% of deaths that occurred in at least one 6-month period during July 2019–December 2024. Includes Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, and Wyoming. Thirty jurisdictions reported data for the full timeframe and 18 reported data for at least one 6-month period.

^cPearson’s chi-square tests were used to compare characteristics of decedents with and without evidence of hepatitis C; Fisher's Exact test was used if any expected cell counts were ≤ 5. Two-sided P-value < 0.05 was considered statistically significant. For variables with more than two categories, Pearson’s chi-square and Fisher’s exact tests were used to identify statistically significant differences between binary subcategories of the main variable by evidence of hepatitis C. All test results of binary subcategories were statistically significant except for the following: age 45–54 (p = 0.97); multi-race, non-Hispanic (p = 0.75); rural urbanization (p = 0.12).

^dMissing/unknown values were excluded from calculations of percentages. Thus, the sum of the counts of each category might not add to the total due to missing data. Percentages might not sum to 100% because of rounding. Overall, < 0.1% of deaths were missing age, < 0.1% were missing sex, 0.8% were missing race/ethnicity, 4.5% were missing education, and 1.4% were missing the county in which the overdose occurred (i.e., to inform urbanization).

^eUrbanization was based on the county in which the overdose occurred and was classified as urban, suburban, or rural using the National Center for Health Statistics 2023 Urban-Rural Classification Scheme for Counties. However, for Connecticut, the 2023 scheme classifies the nine planning regions rather than counties. To align with SUDORS data that only includes counties (i.e., not planning regions), urbanization for Connecticut was based on the 2013 Urban-Rural Classification Scheme for Counties.

^fData on deaths that occurred during July 2019–December 2021 in Kentucky were excluded from urbanization calculations (n = 3887) because 98.6% were missing the county in which the overdose occurred (i.e., to inform urbanization).

3.2. Drugs involved in the fatal overdose

At least one opioid was listed as causing death in 81.8% of decedents with and 80.9% of decedents without evidence of hepatitis C (Table 2). In both groups, most deaths involved IMFs (with evidence of hepatitis C: 70.9%; without evidence of hepatitis C: 71.8%). Stimulants were involved in 62.8% of overdose deaths among decedents with evidence of hepatitis C and 57.1% among decedents without evidence of hepatitis C. A higher percentage of those with evidence of hepatitis C died of methamphetamine-involved overdoses compared to those without evidence of hepatitis C (39.4% vs. 28.2%). Among those with evidence of hepatitis C, 46.6% of deaths involved both opioids and stimulants, 35.1% involved opioids and no stimulants, and 16.2% involved stimulants and no opioids; the pattern was similar to that among decedents without evidence of hepatitis C.

Table 2.

Circumstances surrounding drug overdose deaths stratified by evidence of hepatitis C^a — 47 states and the District of Columbia,^b July 2019–December 2024.

	Evidence of hepatitis C 17,668 (5.4%)	No evidence of hepatitis C 311,086 (94.6%)
	n (%)	n (%)	P-valuec
Drugs involved d
Any opioid	14,450 (81.8)	251,657 (80.9)	< 0.01
Illegally-made fentanyls (IMFs)e	12,527 (70.9)	223,402 (71.8)	< 0.01
Heroinf	2370 (13.4)	33,720 (10.8)	< 0.0001
Prescription opioids	3193 (18.1)	46,038 (14.8)	< 0.0001
Any stimulant	11,104 (62.8)	177,484 (57.1)	< 0.0001
Cocaine	4699 (26.6)	95,743 (30.8)	< 0.0001
Methamphetamine	6961 (39.4)	87,659 (28.2)	< 0.0001
Mutually exclusive opioid and stimulant combinations			< 0.0001
Opioids and stimulants	8240 (46.6)	129,181 (41.5)
Opioids and no stimulants	6210 (35.1)	122,476 (39.4)
Stimulants and no opioids	2864 (16.2)	48,303 (15.5)
Neither opioids nor stimulants	354 (2.0)	11,126 (3.6)
Circumstances Drug use history
History of drug use	15,965 (90.4)	230,686 (74.2)	< 0.0001
History of opioid useg	9926 (56.2)	107,213 (34.5)	< 0.0001
History of illegal opioid use	7450 (42.2)	73,910 (23.8)	< 0.0001
History of stimulant useh	6330 (35.8)	71,650 (23.0)	< 0.0001
Alcohol dependence	5151 (29.2)	57,716 (18.6)	< 0.0001
Any prior nonfatal overdose	4091 (23.2)	38,371 (12.3)	< 0.0001
Nonfatal overdose within one year of death	1929 (10.9)	19,270 (6.2)	< 0.0001
Nonfatal overdose within one month of death	891 (5.1)	9355 (3.0)	< 0.0001
Recent return to use of opioidsi Treatment for substance use disordersj	1794 (10.2)	18,653 (6.0)	< 0.0001
Ever treated for SUDs	5422 (30.7)	46,031 (14.8)	< 0.0001
Ever received medications for opioid use disorder	3353 (19.0)	20,036 (6.4)	< 0.0001
Current treatment for SUDs	2641 (15.0)	19,072 (6.1)	< 0.0001
Select comorbidities
HIV	939 (5.3)	3500 (1.1)	< 0.0001
Current mental health diagnosis	8728 (49.4)	83,494 (26.8)	< 0.0001
History of self-harm, suicidal ideation, or suicide attempt Other circumstances	1756 (9.9)	17,941 (5.8)	< 0.0001
Experiencing homeless or housing instabilityk	2703 (15.6)	29,858 (9.8)	< 0.0001
In custody at the time of the fatal overdose	344 (2.0)	4038 (1.3)	< 0.0001
In jail or prison	239 (1.4)	2199 (0.7)
In other custody	105 (0.6)	1839 (0.6)
Recent release from institutional settingl	2536 (14.5)	26,222 (8.6)	< 0.0001
Hospital	1153 (6.6)	10,385 (3.4)
Jail, prison, or detention facility	706 (4.0)	8792 (2.9)
Supervised residential facility related to alcohol or substance use treatment	363 (2.1)	4507 (1.5)
Other facility	314 (1.8)	2538 (0.8)
Any recent ED visit (within 1 year of death)	3920 (22.3)	33,285 (10.8)	< 0.0001
Recent ED visit within one month of death Overdose circumstances	2030 (11.6)	17,391 (5.6)	< 0.0001
Location of overdose			< 0.0001
House or Apartment	12,218 (69.4)	226,293 (73.0)
Hotel or motel	901 (5.1)	16,455 (5.3)
Street or highway	682 (3.9)	9836 (3.2)
Jail or prison	220 (1.2)	1921 (0.6)
Other location	2828 (16.1)	42,378 (13.7)
Overdose occurred where the decedent lived	9975 (57.9)	184,116 (61.0)
Potential bystander presentm	8024 (45.5)	137,006 (44.1)	< 0.001
Fatal drug use witnessed	1286 (7.3)	25,820 (8.3)	< 0.0001
Naloxone administeredn	4853 (27.5)	69,106 (22.2)	< 0.0001
Emergency Medical Services present	14,966 (85.7)	251,438 (82.2)	< 0.0001

Abbreviations: ED = Emergency Department; ICD–10 = International Classification of Disease 10th Revision; SUDORS = State Unintentional Drug Overdose Reporting System.

^aDecedents were considered to have evidence of hepatitis C if one of the three following criteria were met: the hepatitis C checkbox within the SUDORS web-based system was endorsed; an ICD–10 code consistent with hepatitis C (B17.1, B18.2, B19.2) was present in a multiple cause of death field on the decedent's death certificate; or there was evidence of hepatitis C in the literal cause of death text fields on the decedent's death certificate.

^bTo be included, jurisdictions were required to report ≥ 75% of overdose deaths that occurred in their jurisdiction and abstract medical examiner and coroner reports for ≥ 75% of deaths that occurred in at least one 6-month period during July 2019–December 2024. Includes Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, and Wyoming. Thirty jurisdictions reported data for the full timeframe and 18 reported data for at least one 6-month period.

^cPearson’s chi-square tests were used to compare characteristics of decedents with and without evidence of hepatitis C. Two-sided P-value < 0.05 was considered statistically significant. For variables with more than two categories, Pearson’s chi-square tests were used to identify statistically significant differences between binary subcategories of the main variable by evidence of hepatitis C. All test results of binary subcategories were statistically significant except in other custody at time of the fatal overdose (p = 0.97) and hotel/motel location (p = 0.28).

^dDrugs were classified as involved in overdose deaths if the medical examiner or coroner listed them as causing death on the death certificate, or in the medical examiner or coroner report or postmortem toxicology report.

^eFentanyl was classified as likely illegally made using toxicology, scene, and witness evidence. For the 7.1% of deaths with fentanyl involved that had insufficient evidence for classification as illegal or prescription, fentanyl was classified as illegal because the majority of fentanyl overdose deaths involve illegal fentanyl. All fentanyl analogs except pharmaceutical analogs (i.e., alfentanil, remifentanil, and sufentanil) were included as IMFs.

^fDrugs coded as “Heroin” were heroin and 6-acetylmorphine, a metabolite of heroin. In addition, morphine was coded as heroin if detected along with 6-acetylmorphine, if heroin was listed as a cause of death on the death certificate, or if scene, toxicology, or witness evidence indicated presence of heroin impurities or other illegal drugs, injection, illegal drug use, or a history of heroin use.

^gIncludes history of any opioid use, such as prescription opioid misuse or use of heroin or illegally-made fentanyls.

^hIncludes history of cocaine or methamphetamine use.

ⁱRecent period of opioid use abstinence followed by return to use (within 3 months of the fatal overdose).

^jTreatment for substance use disorders (SUD) includes medications for opioid use disorder (MOUD), living in an inpatient rehabilitation facility, or participation in mental health or SUD outpatient treatment.

^kPersons experiencing homelessness were those who, at the time of the overdose, resided in either places not designed for or ordinarily used as regular sleeping accommodations or in a supervised shelter or drop-in center designated to provide temporary living arrangements, congregate shelters, or temporary accommodations provided by a homeless shelter. Persons experiencing housing instability were not experiencing homelessness but lacked the resources or support networks to obtain or retain permanent housing, including interrelated challenges such as trouble paying rent, overcrowding, moving frequently, or staying with relatives.

^lReleased within a month before death from an institutional setting such as a prison/jail, residential treatment facility, or psychiatric hospital.

^mA potential bystander is defined as a person aged ≥ 11 years who was physically nearby either during or shortly preceding a drug overdose and potentially had an opportunity to intervene or respond to the overdose. This includes any persons in the same structure (e.g., same room or same building, but different room) as the decedent during that time. For example, the family member of an overdose decedent who was in another room during the fatal incident would be considered a potential bystander if that person might have had an opportunity to provide life-saving measures such as administration of medications for opioid overdose reversal (e.g., naloxone), if adequate resources were available and the family member was aware that an overdose event could occur. This does not include, however, persons in different self-contained parts of larger buildings (e. g., a person in a different apartment in the same apartment building would not be considered a potential bystander).

ⁿNaloxone is a type of life-saving medication that can reverse an overdose from opioids, including heroin, fentanyl, and prescription opioid medications. Because SUDORS only includes people who died of a drug overdose, evidence of naloxone administration reflects administration that did not reverse the overdose. This could be because naloxone was not administered soon enough or in sufficient dosages to reverse the overdose, it was not effective (i.e., if the overdose did not involve opioids), or its effectiveness was affected by polydrug use (i. e., if the overdose involved opioids as well as non-opioid drugs).

3.3. Drug use and treatment history

Among decedents with evidence of hepatitis C, 90.4% had a known history of drug use prior to the fatal overdose, compared with 74.2% of decedents without evidence of hepatitis C. Compared with decedents without evidence of hepatitis C, higher proportions of decedents with evidence of hepatitis C had documentation of a history of any opioid use (56.2% vs. 34.5%), illegal opioid use (42.2% vs. 23.8%), stimulant use (35.8% vs. 23.0%), and evidence of a prior nonfatal overdose (23.2% vs. 12.3%).

The percentage of decedents ever treated for SUDs was approximately twice as high among decedents with evidence of hepatitis C compared to those without evidence of hepatitis C (30.7% vs. 14.8%); the percentage ever receiving medications for opioid use disorder was also higher among those with evidence of hepatitis C (19.0% vs. 6.4%). Additionally, decedents with evidence of hepatitis C were more frequently receiving treatment for SUD at the time of death compared to those without evidence of hepatitis C (15.0% vs. 6.1%).

3.4. Select comorbidities

Evidence of human immunodeficiency virus (HIV) was reported for 5.3% of decedents with evidence of hepatitis C, compared with 1.1% of decedents without evidence of hepatitis C. Approximately half (49.4%) of decedents with evidence of hepatitis C had a current mental health diagnosis at the time of the fatal overdose. In comparison, 26.8% of decedents without evidence of hepatitis C had a current mental health diagnosis. A history of self-harm, suicidal ideation, or suicide attempt was reported for 9.9% of those with evidence of hepatitis C compared with 5.8% of those without evidence of hepatitis C.

3.5. Other circumstances

Decedents with evidence of hepatitis C were slightly more often experiencing homelessness or housing instability compared to those without evidence of hepatitis C (15.6% vs. 9.8%) (Table 2). Although the overall number of fatal overdoses occurring in jails or prisons was low, the percentage of decedents with evidence of HCV infection that died while in custody of a jail or prison was approximately twice that of decedents without evidence of hepatitis C (1.4% vs. 0.7%). Decedents with evidence of hepatitis C had also more frequently been recently released from an institutional setting (14.5% vs. 8.6%), particularly a hospital (6.6% vs. 3.4%) or jail, prison, or detention facility (4.0% vs. 2.9%), compared to decedents without evidence of hepatitis C.

3.6. Recent touchpoints and opportunities for intervention

The percentage of decedents with evidence of hepatitis C who visited an ED or urgent care within one year of death was twice that of decedents without evidence of hepatitis C (22.3% vs. 10.8%). Similarly, a higher percentage of decedents with evidence of hepatitis C compared with decedents without evidence of hepatitis C had visited an ED or urgent care within one month before death (11.6% vs. 5.6%).

Among decedents with evidence of hepatitis C, 40.3% had at least one recent touchpoint or potential opportunity for intervention (Fig. 1). In contrast, this percentage was 23.9% for decedents without evidence of hepatitis C. For all recent touchpoints or intervention opportunities, the percentage was higher among those with evidence of hepatitis C than those without evidence of hepatitis C.

Fig. 1.

Percentage of drug overdose deaths with evidence of at least one recent touchpoint or potential opportunity for intervention^a stratified by evidence of hepatitis C^b,c — 47 states and the District of Columbia,^d July 2019–December 2024. Abbreviations: ICD–10 = International Classification of Disease 10th Revision; SUDORS = State Unintentional Drug Overdose Reporting System. ^a At least one recent touchpoint or potential opportunity for intervention is a composite variable including release from an institutional setting within one month of death, treatment for substance use or mental health disorders within two months of death, emergency department or urgent care visit within one month of death, and nonfatal overdose within one month of death. ^b Decedents were considered to have evidence of hepatitis C if one of the three following criteria were met: the hepatitis C checkbox within the SUDORS web-based system was endorsed; an ICD–10 code consistent with hepatitis C (B17.1, B18.2, B19.2) was present in a multiple cause of death field on the decedent's death certificate; or there was evidence of hepatitis C in the literal cause of death text fields on the decedent's death certificate. ^c Pearson’s chi-square tests were used to compare characteristics of decedents with and without evidence of hepatitis C. Two-sided P-value < 0.05 was considered statistically significant. All five comparisons (i.e., one for each variable) yielded P-values < 0.0001. ^d To be included, jurisdictions were required to report ≥ 75% of overdose deaths that occurred in their jurisdiction and abstract medical examiner and coroner reports for ≥ 75% of deaths that occurred in at least one 6-month period during July 2019–December 2024. Includes Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, and Wyoming. Thirty jurisdictions reported data for the full timeframe and 18 reported data for at least one 6-month period.

3.7. Trends

During July 2019–December 2024, 250,583 overdose deaths with data available on circumstances were reported across 29 states and DC. The total number of overdose deaths increased from 18,083 deaths during July—December 2019, peaking at 26,115 during January—June 2023, and declining to 17,354 during July—December 2024. The number of persons who died of an overdose with evidence of hepatitis C increased from 950 during July–December 2019–1258 during July–December 2024; the percentage increased from 5.3% to 7.2% during the same timeframe (Cochran-Armitage test for trend p < 0.0001) (Fig. 2). Despite recent declines in overdose deaths, the percentage with evidence of hepatitis C was highest in the most recent 6-month period (July—December 2024). Among decedents with evidence of hepatitis C, the percentage with evidence of injection drug use decreased from 41.1% during July–December 2019 to 26.3% during July–December 2024 (p < 0.0001); the percentage decreased from 24.5% to 13.1% among those without evidence of hepatitis C (p < 0.0001) (Fig. 3). In contrast, the percentage with evidence of smoking increased from 9.4% during July–December 2019 to 35.3% during July–December 2024 among those with evidence of hepatitis C (p < 0.0001) and from 11.7% to 29.5% among those without evidence of hepatitis C (p < 0.0001). Although decreases in evidence of injection drug use and increases in smoking were observed among both those with and without evidence of hepatitis C, smoking became the most common route of drug use (based on scene evidence at the fatal overdose) among those with evidence of hepatitis C later (January–June 2023) than it did among those without evidence of hepatitis C (July–December 2021).

Fig. 2.

Number and percentage of drug overdose deaths with evidence of hepatitis C^a by six-month period of death —29 states and the District of Columbia,^b July 2019–December 2024. Abbreviations: ICD–10 = International Classification of Disease 10th Revision; SUDORS = State Unintentional Drug Overdose Reporting System. ^a Decedents were considered to have evidence of hepatitis C if one of the three following criteria were met: the hepatitis C checkbox within the SUDORS web-based system was endorsed; an ICD–10 code consistent with hepatitis C (B17.1, B18.2, B19.2) was present in a multiple cause of death field on the decedent's death certificate; or there was evidence of hepatitis C in the literal cause of death text fields on the decedent's death certificate. ^b To be included, jurisdictions were required to report ≥ 75% of overdose deaths in their jurisdiction and abstract medical examiner and coroner reports for ≥ 75% of deaths that occurred during July 2019–December 2024. Includes Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, District of Columbia, Georgia, Illinois, Kansas, Kentucky, Maine, Maryland, Massachusetts, Minnesota, Nebraska, New Hampshire, New Jersey, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Utah, Vermont, Virginia, Washington, and West Virginia.

Fig. 3.

Percentage of drug overdose deaths with evidence of each route of drug use^a,b stratified by evidence of hepatitis C^c and reported by six-month period of death — 29 states and the District of Columbia,^d July 2019–December 2024. Abbreviations: ICD–10 = International Classification of Disease 10th Revision; SUDORS = State Unintentional Drug Overdose Reporting System. ^a Percentages with evidence of other routes (i.e., buccal, sublingual, suppository, or transdermal) (n = 1062; 0.4%) are not presented because of small sample sizes; decedents with drug use via these routes are included in the denominators. In addition, percentages of decedents with no information on route (121,198; 48.4%) are not shown; these decedents are also included in the denominators. The percentage with no information on route remained stable throughout the timeframe. ^b Evidence of ingestion included witness reports of taking pills or tablets orally or ingesting liquid orally, or the discovery of pills, pill bottles, liquid substances, or vials for liquid substance at the scene of the overdose. Evidence of injection included witness reports of injecting, items used to prepare and inject substances found at the scene (e.g., needles, cookers, filters, tourniquets, alcohol pads), or track marks found on decedent that appear to be recent. Evidence of smoking included witness reports of smoking or drug paraphernalia associated with smoking such as pipes, stems, tinfoil, and vape pens found at the scene. Evidence of snorting included witness reports of snorting, drug paraphernalia associated with snorting such as razor blades, credit cards, straws, rolled paper, dollar bills, or tubes found at the scene, powder visible on a table/mirror, or powder on the decedent’s nose. Routes of drug use are not mutually exclusive; decedents might have used drugs by multiple routes. ^c Decedents were considered to have evidence of hepatitis C if one of the three following criteria were met: the hepatitis C checkbox within the SUDORS web-based system was endorsed; an ICD–10 code consistent with hepatitis C (B17.1, B18.2, B19.2) was present in a multiple cause of death field on the decedent's death certificate; or there was evidence of hepatitis C in the literal cause of death text fields on the decedent's death certificate. ^d To be included, jurisdictions were required to report ≥ 75% of overdose deaths in their jurisdiction and abstract medical examiner and coroner reports for ≥ 75% of deaths that occurred during July 2019–December 2024. Includes Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, District of Columbia, Georgia, Illinois, Kansas, Kentucky, Maine, Maryland, Massachusetts, Minnesota, Nebraska, New Hampshire, New Jersey, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Utah, Vermont, Virginia, Washington, and West Virginia.

3.8. Sensitivity analyses

Sensitivity analyses comparing circumstances surrounding the fatal overdose for those with evidence of hepatitis C to those without evidence of hepatitis C but with a history of heart disease (Table A.1, Figure A.1, Figure A.2), and analyses restricting sociodemographic, toxicology, and circumstance analyses to the same jurisdictions as were included in the trend analysis (29 states and DC; Table B.1, Table B.2, Figure B.1) yielded the same conclusions as the primary analyses.

4. Discussion

Evidence of hepatitis C was reported for a small percentage of overdose decedents overall, although the prevalence increased from late 2019 to late 2024. Expectedly, those with evidence of hepatitis C more often had evidence of injection drug use than those without evidence of hepatitis C. Those with evidence of hepatitis C also had higher prevalences of various circumstances (e.g., nonfatal overdoses, mental health diagnoses, SUD treatment), which could indicate a longer and more complex trajectory of drug use that both increases risk for hepatitis C and offers opportunities and touchpoints to prevent infection and fatal overdose.

The rise in injection drug use in the U.S. has been the primary driver for acute HCV infection (Centers for Disease Control and Prevention, 2025; Shepard et al., 2005). Despite overall decreases in drug overdose deaths with evidence of injection from the start (July–December 2019) to the end (July–December 2024) of the study period in this analysis, the percentage of persons who died of an overdose with evidence of hepatitis C increased slightly from 5.3% to 7.2%. Unsurprisingly, and despite shifting trends in routes of drug use, those with evidence of hepatitis C had nearly twice the percentage with evidence of injection drug use compared to those without evidence of hepatitis C across the entire timeframe. Although rare, decedents with evidence of hepatitis C also more frequently had HIV compared to those without evidence of hepatitis C. Implementation of evidence-based services have been shown to mitigate some of the infectious disease consequences of injection drug use, including hepatitis C and HIV (Aspinall et al., 2014; Centers for Disease Control and Prevention, 2025; Patel et al., 2018; Taylor et al., 2021). Community-based prevention programs which provide access to overdose prevention tools, such as opioid overdose reversal medications (OORMs, e.g., naloxone), and link persons to care for evidence-based treatment of SUDs and infectious disease also continue to be important for addressing the hepatitis C, HIV, and overdose syndemic (Centers for Disease Control and Prevention, 2024; Centers for Disease Control and Prevention, 2025; Centers for Disease Control and Prevention, 2025; Perlman and Jordan, 2018).

Those with evidence of hepatitis C were more commonly older and non-Hispanic White compared to those without evidence of hepatitis C. This is potentially because of higher past or current prevalence of injection drug use among these groups (Bradley et al., 2023). Older persons might have a longer history of drug use, and might have initiated drug use during a time when injection was most common, thereby increasing risk of hepatitis C. Additionally, the prevalence of injection drug use is higher among the U.S. adult non-Hispanic White population compared to other racial/ethnic groups (Bradley et al., 2023). Efforts to engage these persons in, and expand options for, primary and secondary prevention programs might reduce risk of hepatitis C and related co-morbidities and prevent overdose. For example, older adults are less likely to undergo screening for SUDs and enter specialized addiction treatment programs; instead, provision of these services in emergency departments, senior centers, and primary care offices might improve reach to older persons and reduce risk of infectious diseases and overdose (Kuerbis et al., 2014; Substance Abuse and Mental Health Services Administration, 2020).

Nearly half of decedents with evidence of hepatitis C had a current mental health diagnosis, almost twice the percentage of those without evidence of hepatitis C. Additionally, approximately 10% of decedents with evidence of hepatitis C had a history of self-harm, suicidal ideation, or suicide attempt, compared to less than 6% of decedents without evidence of hepatitis C. Even among persons infected with HCV without cirrhosis-associated hepatic encephalopathy, extrahepatic symptoms, including neurological systems and mental health disorders (e.g., depression, cognitive decline), are common (Boscarino et al., 2015; Faccioli et al., 2021; Perry et al., 2008). Through improvements in testing, diagnosis, and curative treatment, it is possible that some of these extrahepatic symptoms may improve (Faccioli et al., 2021). Additionally, mental health disorders and SUDs frequently co-occur and are interconnected (e.g., use of substances to cope with mental health disorders) (Iqbal et al., 2019; Santucci, 2012). Comprehensive screening and testing, and integration of treatments for infectious diseases, mental health, and SUDs, might reduce associated morbidity and mortality, particularly among persons with hepatitis C.

Decedents with evidence of hepatitis C had at least one recent touchpoint or potential opportunity for intervention, including recent release from an institutional setting (e.g., jail or prison), treatment for mental health or SUDs, an ED or urgent care visit, or a previous nonfatal overdose nearly twice as often as decedents without evidence of hepatitis C (40.3% vs. 23.9%). CDC recommends universal hepatitis C screening for all adults 18 years and older at least once in their lifetime as well as routine periodic testing for persons with ongoing risk factors, such as PWID (Centers for Disease Control and Prevention, 2025). Ensuring risk-based testing, diagnosis, and referral to treatment for hepatitis C is crucial to reduce further transmission of the virus. It is imperative that testing programs are accessible for priority populations to ensure success. Newly approved HCV RNA point of care testing devices, which can be used in non-clinical settings and require only fingerstick capillary blood (and thus don’t require trained phlebotomists to obtain a sample), can substantially reduce the time to diagnosing current infection (Centers for Disease Control and Prevention, 2024). These devices might be useful for hepatitis C testing and diagnosis particularly in high prevalence settings like jails, prisons, community-based prevention programs, and SUD clinics.

In addition to testing, diagnosis, and referral to treatment for hepatitis C, these touchpoints also serve as important access points for overdose prevention. Expansion of SUD screening, treatment, and linkage to care as well as provision of OORMs and other services in EDs or urgent care settings, institutions (e.g., jails, prisons), and within SUD or mental health treatment settings might further prevent infectious disease transmission and reduce overdose morbidity and mortality. Persons who died with evidence of hepatitis C more often had a prior nonfatal overdose both ever and within one month compared to those without evidence of hepatitis C. Nonfatal overdoses serve as opportunities for post-overdose response efforts (e.g., via peer navigators, public safety officials) to engage persons at high risk for fatal overdose (Krawczyk et al., 2020) in evidence-based overdose prevention interventions, such as SUD treatment, provision of OORMs, and education on substance use risk (Centers for Disease Control and Prevention, 2022; Formica et al., 2022). Collectively, two out of five persons who died of an overdose with evidence of hepatitis C had a potential touchpoint or opportunity to prevent the fatal overdose and represent missed chances to prevent infectious disease spread and overdose; utilizing these opportunities is essential for diagnosis and treatment of hepatitis C and saving lives from overdose.

4.1. Limitations

First, this analysis likely underestimates the true percentage of persons who died from overdose with hepatitis C. An analysis of SUDORS data on overdose deaths in Tennessee during 2019–2020 found the proportion with evidence of hepatitis C to be nearly five times that of this study (24.6% vs. 5.4%) (Korona-Bailey et al., 2023). The higher percentage of decedents with hepatitis C in the Tennessee study is likely because they were able to link SUDORS data with laboratory data from the state HCV surveillance registry; this was not possible in this analysis because unique patient identifiers are not available across datasets. However, this study yielded similar patterns to the published Tennessee study. Second, SUDORS data on hepatitis C cannot differentiate between current or past infection; thus, it’s possible that some decedents had spontaneously resolved infection or been treated for infection prior to death. It is more likely that infection noted in source documents related to the fatal overdose reflects current or recent infection rather than remote or cured infections. Regardless of whether the decedent had current HCV infection at the time of death, findings describe noteworthy behavioral patterns among persons who use drugs that may exacerbate risk for hepatitis C. Third, data on circumstances surrounding overdose deaths are based on availability in investigative reports (e.g., medical examiner or coroner reports); percentages of deaths with each circumstance are likely underestimated. Additionally, those with evidence of hepatitis C in SUDORS might have had better documentation in investigative reports or better access to healthcare, both resulting in them being classified as having hepatitis C and resulting in this group having higher percentages of some circumstances. However, sensitivity analyses comparing those with evidence of hepatitis C to those without evidence of hepatitis C but with a history of heart disease (i.e., a group also likely to have improved documentation) yielded similar results. Lastly, analyses, particularly trend analyses, included a subset of jurisdictions and might not be generalizable to the entire U.S.

5. Conclusion

This study highlights the need for a syndemic-focused approach to address the overlapping epidemics of hepatitis C and drug overdose. CDC has set ambitious goals for eliminating hepatitis C as a public health threat by 2030 (Centers for Disease Control and Prevention, 2020), but this can only be achieved by simultaneously addressing the epidemic of drug overdose. One of the primary goals of the Office of National Drug Control Policy (ONDCP) is to protect the health and safety of all Americans by increasing the number of people receiving evidence-based treatment and preventing drug use before it starts (The White House Executive Office of the President, Office of National Drug Control Policy, 2025). To meet the interconnected goals set by CDC and ONDCP, public health must prioritize several key activities: 1) implementation of community-based prevention services to prevent spread of infectious diseases and distribution of overdose prevention tools like OORMs; 2) robust and accessible testing for hepatitis C and HIV among PWID; 3) linkage to care and evidence-based treatments for substance use disorders (e.g., medications for opioid use disorder) and mental health; 4) linkage to care and curative treatment for hepatitis C; and 5) robust public health surveillance to monitor trends and identify populations in need of tailored prevention efforts.

Glossary

CDC

Centers for Disease Control and Prevention

ED

Emergency department

HCV

Hepatitis C virus

HHS

U.S. Department of Health and Human Services

HIV

Human immunodeficiency virus

ICD-10

International Classification of Disease 10^th revision

IMFs

Illegally-made fentanyls

OORMs

Opioid overdose reversal medications

PWID

Persons who inject drugs

RNA

Ribonucleic acid

SUDORS

State Unintentional Drug Overdose Reporting System

SUDs

Substance use disorders

Appendix A. Supporting information

Supplementary data associated with this article can be found in the online version at doi:10.1016/j.drugalcdep.2026.113295.