Visualizing the Impact of the Opioid Overdose Crisis

Although final death statistics are currently available from the Centers for Disease Control and Prevention (CDC), only through 2020, provisional data also compiled by the CDC show a rise in opioid deaths when COVID-19 lockdowns began in March 2020. The rise is particularly notable for deaths involving synthetic opioids. Factors related to the pandemic, such as stress, social isolation, and using these substances alone, likely exacerbated the increase in overdose deaths. Additionally, lockdowns made it challenging for people to receive in-person treatment for existing substance abuse problems, harm reduction services, and emergency services.

Since 2000, there has been a more than 1,000% increase in opioid overdose deaths. As the rate of deaths grew, the minutes between deaths fell correspondingly. By 2020, one person was dying of an opioid overdose every 7.75 minutes. Nearly 75% of drug overdose deaths in 2020 involved an opioid.

Over this period, the crisis evolved in three well-documented waves. Initially, overdose deaths were predominantly linked to common prescription opioids. Despite a recent decline in deaths involving prescription opioids, there was an uptick in 2020. Heroin was increasingly involved in overdose deaths since 2011 but began declining in 2016. Beginning in 2014, there was an explosion in the number of deaths involving synthetic opioids such as fentanyl. The source of fentanyl driving the increase in synthetic opioid-involved deaths is more likely to be illicitly manufactured than pharmaceutical. Because a single death may involve multiple types of opioids, summing across the three categories in any year will overstate the total number of
deaths in that year.

Over this period, opioid overdose death rates have increased in all racial and ethnic groups, but disparities exist between some groups. The opioid crisis initially affected White Americans more because they are much more likely to be prescribed opioid painkillers. However, the demographics have been shifting for years and the opioid death rate among Black or African Americans and American Indians or Alaskan (AI/AN) surpassed other racial groups in recent years.

The main driver of opioid overdose deaths in Black communities is fentanyl. There are also disparities in access to effective evidence-based treatments and naloxone. The increase in opioid overdose deaths among AI/AN is due to opioids alone and in combination with alcohol, benzodiazepines, cocaine and methamphetamine. Many underlying social factors driving this pattern include socioeconomic inequity, historical trauma, and inequities in healthcare access and treatment programs.

Race and ethnicity were used as defined in the WONDER and NCHS databases. Racial and ethnic groups were defined first by ethnicity (Hispanic or Latino) and subsequently by race (non-Hispanic American Indian or Alaska Native, non-Hispanic Black or African American, non-Hispanic White, and non-Hispanic Asian or Pacific Islander).

The three waves of the opioid crisis are also apparent when looking at temporal changes in the share of opioid deaths in a given year that involved each substance. At the beginning of the period, 65 percent of all opioid overdose deaths involved common prescription pain killers, but this figure had declined to 24 percent by 2020. Deaths involving heroin began playing a larger role in overdose deaths around 2011, before beginning to tail off after 2015. While heroin-involved overdose death rates decreased nearly 7 percent from 2019 to 2020, nearly 20% of all opioid deaths involved heroin. These decreases are supplanted by the very significant rise in the involvement of synthetic opioids, primarily fentanyl. By 2020, 83 percent of all opioid deaths involved a synthetic product. Again, since multiple substances may be involved in a single death, the percentages reflecting the share of total deaths involving each substance will sum to more than 100 percent in a given year.

In the panel above, we present unduplicated counts of the number of deaths involving specific combinations of prescription opioids, heroin and synthetic opioids. There is a growing share of opioid deaths involving two or even all three of these substances, particularly in recent years. It is also apparent the large uptick in opioid overdose deaths can be attributed to use of only synthetic opioids.

In the second tab, focusing on common prescription opioids, we see a leveling off and then a decline in the number of deaths attributable solely to this type of opioid (the dark blue segments), as well as the increasing involvement of heroin and/or synthetic opioids used in combination with prescription drugs. The majority of polysubstance deaths involve synthetic opioids.

In the third tab, we see deaths involving only heroin began to rise in 2011 and deaths involving both heroin and synthetic opioids increased rapidly from 2014 onward.

Finally, data presented in the fourth tab show not only the rising importance of synthetics as the sole cause of opioid overdoses, but also how common it has become for overdose deaths to involve synthetic products in combination with heroin and/or prescription opioids.

The burden of opioid deaths is spread unevenly across the U.S. Synthetic opioid death rates are higher in the eastern portion of the U.S., which has been attributed to the fact that powdered heroin is typically used in this area of the country, and is more easily mixed with synthetic opioids, making for a potent and deadly combination. In contrast, the heroin used in the western portion of the country is a tar-like substance that does not mix easily with synthetic opioids, providing a small measure of protection against unintended heroin overdoses. From 2019 to 2020, synthetic opioid death rates increased by over 56% in the U.S. In contrast, heroin death rates decreased by nearly 7% from 2019 to 2020 with increases in only several states. For prescription opioids, while there are some state hot spots with elevated death rates, strong geographic patterns are harder to detect.

The impact of the opioid crisis continues to increase across all age groups. In the early years when opioid abuse was primarily associated with prescription pain medications, the crisis was initially felt most acutely by adults in their 40s. Beginning around 2007 overdose deaths began to affect all age groups more equally. By the end of the period, when synthetic opioids had come to dominate the crisis, younger adults aged 25 to 40 were the hardest hit by overdose deaths.

Strategies to reduce drug overdose deaths include promoting evidence-based solutions in prevention, harm reduction, treatment and recovery efforts. Additionally, efforts are needed to improve data collection. This includes the collection of timely and local data, making real-time data available for analysis, and using gathered information to inform community-tailored interventions.

Data on opioid overdose deaths were derived from the multiple cause of death files of the Wide-ranging Online Data for Epidemiologic Research (WONDER) data system maintained by the Centers for Disease Control and Prevention (CDC).

Deaths were identified as due to an opioid overdose if the ICD-10 code for the underlying cause of death was X40-X44 (accidental poisoning), X60-X64 (intentional self-poisoning) or Y10-14 (poisoning of undetermined intent) and if any of the multiple cause of death codes indicated that the type of substance involved in the poisoning was T40.1 (heroin), T40.2 (natural and semi-synthetic opioids), T40.3 (methadone) or T40.4 (synthetic opioids other than methadone). Because a single death may involve multiple substances, summing across the number of deaths involving each substance will overestimate the number of opioid-related overdoses. Following the classification scheme adopted by the CDC, methadone and natural and semi-synthetic opioids (e.g., oxycodone and hydrocodone) were grouped into a single category encompassing commonly prescribed opioids. Synthetic opioids other than methadone include substances such as tramadol and fentanyl (both pharmaceutically manufactured and illicitly manufactured). A small number of opioid deaths that were the result of homicide (underlying cause of death X85) were excluded from the analyses.

Provisional death data come from the CDC’s National Center for Health Statistics Provisional Drug Overdose Death Counts, and capture the same three substance categories used in other panels: heroin (T40.1); commonly prescribed opioids (T40.2 and T40.3); and synthetic opioids other than methadone (T40.4). Provisional death data are based on death records submitted by state vital registration offices and vary in their timeliness for both reporting and validation. The counts given for a specific month capture all death reports for the prior twelve-month period ending in that month, making the counts insensitive to variation in reporting across seasons. In addition to the raw provisional counts, the CDC also provides predicted provisional counts that have been adjusted to account for reporting and validation delays. The graphic we show is based on these predicted provisional counts. Provisional data are subject to change and are not strictly comparable with final annual death counts reported elsewhere.

Prevention, Harm Reduction, Treatment, Recover: Speakers on NIHCM’s May 24, 2021 webinar, Addressing the Growing Overdose and Addiction Epidemic, offered a range of strategies to respond to the crisis of drug overdose deaths. These strategies are summarized broadly here using a framework centered around evidence-based prevention, harm reduction, treatment and recovery strategies

Data collection: National Institute on Drug Abuse, “Disparities in opioid overdose deaths continue to worsen for Black people, study suggests”