Demographic and Geographic Variation in Fatal Drug Overdoses in the United States, 1999–2020

AuthorShannon M. Monnat
Published date01 September 2022
Date01 September 2022
50 ANNALS, AAPSS, 703, September 2022
DOI: 10.1177/00027162231154348
and Geographic
Variation in
Fatal Drug
Overdoses in
the United
States, 1999–
The U.S. drug overdose crisis has been described as a
national disaster that has affected all communities. But
overdose rates are higher among some subpopulations
and in some places than they are in others. This article
describes demographic (sex, racial/ethnic, age) and
geographic variation in fatal drug overdose rates in the
United States from 1999 to 2020. Across most of that
timespan, rates were highest among young and middle-
age (25–54 years) White and American Indian males
and middle-age and older (45+ years) Black males.
Rates have been consistently high in Appalachia, but
the crisis has spread to several other regions in recent
years, and rates are high across the urban-rural contin-
uum. Opioids have been the main contributor, but
overdoses involving cocaine and psychostimulants have
also increased dramatically in recent years, demonstrat-
ing that our problem is bigger than opioids. Evidence
suggests that supply-side interventions are unlikely to
be effective in reducing overdoses. I argue that the U.S.
should invest in policies that address the upstream
structural drivers of the crisis.
Keywords: opioids; drug overdose; demographic dif-
ferences; geographic differences
Fatal drug overdose rates in the U.S.
increased 445 percent from 1999 to 2020,
claiming the lives of over one million Americans.
The primary contributor has been opioids, due
largely to their comparative lethality relative to
other commonly used substances. Indeed, 75
percent of overdoses between 1999 and 2020
involved opioids (author calculations). However,
deaths involving cocaine, psychostimulants
with abuse potential (primarily methampheta-
mine), and prescription benzodiazepines (a
Shannon M. Monnat is Lerner Chair in Public Health
Promotion and Population Health, director of the
Center for Policy Research, and professor of sociology at
Syracuse University. Her research examines demographic
and geographic variation in health and mortality, with
emphasis over the past several years on explaining
variation in drug overdose mortality.
sedative) also increased over this period, demonstrating that our problem is big-
ger than opioids alone. Despite the billions of dollars invested and numerous
policies enacted to combat the drug overdose epidemic, overdose rates continue
to climb, and the COVID-19 pandemic appears to have exacerbated these long-
term trends (National Center for Health Statistics [NCHS] 2022).
The U.S. drug overdose crisis has been described as a national crisis affecting
all groups and geographic areas. However, overdose rates are higher and have
increased more in some subpopulations and places than others. A report released
by the National Academies of Sciences, Engineering, and Medicine (NASEM;
2021), examining mortality trends among U.S. working-age (25–64 years) non-
Hispanic (NH) Whites, NH Blacks, and Hispanics, found that fatal drug over-
dose rates from 1999 to 2017 were highest among White males 25 to 44 years old
and Black males 55 to 64 years old. Hoopsick, Homish, and Leonard (2021)
examined fatal overdoses involving specific opioids among U.S. Whites, Blacks,
and Hispanics ages 45 to 64 from 1999 to 2018, finding that Whites had the high-
est rates involving prescription opioids, while Blacks had significantly higher
rates from heroin and synthetic opioids. In terms of geographic differences,
analyses show that rates have been highest over the past two decades in
Appalachia and the desert Southwest, with larger swaths of the country (New
England, parts of the Industrial Midwest, and eastern Oklahoma) experiencing
surging rates since the mid-2010s (Monnat et al. 2019; Peters et al. 2020).
Whereas overdoses involving prescription opioids have generally been highest in
nonmetro areas, overdoses involving heroin and synthetic opioids have been
higher in metro areas (Rigg et al. 2018; Peters et al. 2020).
This article presents a broad overview of where and among whom the contem-
porary drug overdose crisis has had its most pronounced effects. I do this by
presenting a comprehensive summary of demographic (age group, sex, racial/
ethnic) and geographic variation in fatal drug overdose trends from 1999 to 2020.
I consider a wider range of age groups than prior analyses that tend to focus on
working-age adults, include American Indians and Asians, update analyses to
2020 (the most recent year for which data are available and the year with the
highest overdose rate in the U.S. to date), and consider variation across the dif-
ferent waves of the overdose crisis, wherein different drugs have played a pri-
mary role during different periods.
My analyses also extend beyond opioids to consider the role of other high-risk
drugs—cocaine, psychostimulants with abuse potential, and benzodiazepines.
NOTE: The author acknowledges research funding from the National Institute on Drug Abuse
(U01 DA055972) and the National Institute on Aging (NIA)–funded Center for Aging and
Policy Studies at Syracuse University (P30AG066583) and support from two research networks
funded by the NIA (R24 AG065159 and 2R24 AG045061), the NICHD (National Institute of
Child Health and Human Development)-funded Population Research Institute at Pennsylvania
State University State (P2CHD041025), the Rural Population Research Network – a U.S.
Department of Agriculture (USDA) Agricultural Experiment Station Multistate Research
Project (W5001), and the Syracuse University Lerner Center for Public Health Promotion and
Population Health.

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