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

• DOI: http://doi.org/10.1177/00027162231154348
• Published date: 01 September 2022
• Date: 01 September 2022

50 ANNALS, AAPSS, 703, September 2022

DOI: 10.1177/00027162231154348

Demographic

and Geographic

Variation in

Fatal Drug

Overdoses in

the United

States, 1999–

2020

By

SHANNON M. MONNAT

1154348ANN THE ANNALS OF THE AMERICAN ACADEMYVARIATION IN FATAL DRUG OVERDOSES IN THE U.S.

research-article2023

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

Correspondence: smmonnat@syr.edu

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.

VARIATION IN FATAL DRUG OVERDOSES IN THE U.S. 51

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.