Opioid overdose deaths continue to increase in the United States, reaching 49 860 in 2019, the highest ever recorded.¹ Non-Hispanic White individuals were disproportionately affected in the wave of prescription opioid deaths at the turn of the century; however, recent increases driven by heroin and fentanyl have been greater for non-Hispanic Black and Hispanic individuals.^2,3 Racial inequities in US drug policy are well chronicled.⁴ These inequities include more severe criminal penalties for crack cocaine, more commonly used by Black individuals, compared with those for powder cocaine, more commonly used by non-Hispanic White individuals. Furthermore, the increase in opioid overdose deaths among non-Hispanic White individuals was associated with a shift toward a public health approach encompassing compassion and treatment.⁴

The Helping to End Addiction Long-term Communities Study (HCS) is an ongoing multisite, parallel-group, cluster-randomized, wait list–controlled trial in 67 communities disproportionately affected by opioid overdose deaths in 4 states (Kentucky, Massachusetts, New York, and Ohio).⁵ HCS, the largest addiction implementation study ever conducted, is evaluating the impact of a community engagement intervention to reduce opioid overdose deaths. In the planning stage, community coalitions requested data by race/ethnicity to focus on equity. HCS created the infrastructure to provide data on opioid overdose deaths by race/ethnicity at the community level in a more timely and detailed manner than available through publicly available resources.⁶ We reported trends in opioid overdose deaths by race/ethnicity from 2018 to 2019 during the preintervention baseline period in the 67 HCS communities. These trends directly informed community intervention planning.

METHODS

We identified opioid overdose deaths for individuals aged 18 years or older for the 67 communities enrolled in HCS. We used death certificate records from the offices of vital statistics in Kentucky, Massachusetts, Ohio, and New York, consistent with the recommended approach of the Centers for Disease Control and Prevention ([CDC]; Appendix [available as a supplement to the online version of this article at http://www.ajph.org]).⁶ We analyzed race/ethnicity to capture unmeasured social factors, including the experience of racism. We assigned individuals to 1 of 4 mutually exclusive race/ethnicity categories (non-Hispanic White, non-Hispanic Black, Hispanic, or other) using death certificate data. We obtained HCS community population size estimates stratified by race/ethnicity for individuals aged 18 years or older using the 2018 National Center for Health Statistics bridged-race population estimates and the 2014 to 2018 American Community Survey population estimates (Appendix).

We calculated opioid overdose death rates per 100 000 adults for calendar years 2018 and 2019 overall and stratified them by race/ethnicity and state. We used Poisson distribution to model deaths and Poisson regression with the logarithm of population as an offset variable to estimate the significance of changes in opioid overdose death rates by year and race/ethnicity.^7,8 In each racial/ethnic group, we calculated the ratio of the 2019 versus 2018 annual rates and its 95% confidence interval (95% CI). To determine whether changes in annual opioid overdose death rates differed by race/ethnicity, we calculated a ratio of rate ratios (RRR), comparing the rate ratio (RR) for each racial/ethnic group to non-Hispanic White individuals as a reference.

RESULTS

The total population aged 18 years or older across the 67 HCS communities was 8 316 922. The race/ethnicity distribution was 73% non-Hispanic White, 15% non-Hispanic Black, 7% Hispanic, and 6% other races/ethnicities. We identified 3188 opioid overdose deaths in 2018 and 3282 deaths in 2019, corresponding to opioid overdose death rates of 38.3 and 39.5 per 100 000 for 2018 and 2019, respectively. We identified no statistically significant difference in the overall opioid overdose death trend from 2018 to 2019 (RR = 1.03; 95% CI = 0.98, 1.08; Table 1). We observed a 14% decrease in the opioid overdose death rate in New York HCS communities (RR = 0.86; 95% CI = 0.77, 0.96) but no significant changes in other states.

TABLE 1—Trends in Opioid Overdose Death Rates by Race/Ethnicity, Across HEALing Communities Study Communities: Kentucky, New York, Massachusetts, and Ohio, 2018–2019

We observed a 38% overall increase in the opioid overdose death rate for non-Hispanic Black individuals from 2018 to 2019 (RR = 1.38; 95% CI = 1.21, 1.57) but no change overall among the other racial/ethnic groups. We found opioid overdose death rate increases among non-Hispanic Black individuals in Kentucky (RR = 1.46; 95% CI = 1.01, 2.11) and Ohio (RR = 1.45; 95% CI = 1.24, 1.70) and a nonstatistically significant 26% increase among non-Hispanic Black individuals in Massachusetts (RR = 1.26; 95% CI = 0.73, 2.18). Although opioid overdose death rates were unchanged for non-Hispanic Black individuals in New York (RR = 1.03; 95% CI = 0.72, 1.48), this is amid an 18% decline among non-Hispanic White individuals (RR = 0.82; 95% CI = 0.72, 0.93).

Compared with non-Hispanic White individuals, there was a significant increasing trend in opioid overdose deaths among non-Hispanic Black individuals across all HCS communities (RRR = 1.40; 95% CI = 1.22, 1.62; Table 1). Although these trends were observed in all 4 states, statistically significant differences were identified only in Kentucky and Ohio.

DISCUSSION

Across the 67 HCS communities, opioid overdose death rates were flat between 2018 and 2019. However, in these communities highly affected by opioid overdoses, we identified marked disparities by race/ethnicity, with a 38% increase in opioid overdose deaths among non-Hispanic Black individuals. Unfortunately, these data confirm that disparities in opioid overdose fatality trends by race/ethnicity observed through 2018 in previous studies continue to widen.^2,3

Public health leaders have called for the use of critical race theory to intentionally address structural racism in the development and execution of policy, practice, and research to ensure that gains from addressing opioid use disorder are achieved equitably.⁴ The director of the National Institute on Drug Abuse highlighted the impact of structural racism on emerging overdose disparities and the need for research to ameliorate these disparities.⁹ HCS recognizes that interventions aimed at reducing opioid overdose deaths may worsen underlying disparities and has made an explicit commitment to equity.¹⁰

HCS is striving to increase evidence-based practices, including overdose education and naloxone distribution and enhanced delivery of medications for opioid use disorder.⁵ Disparities in overdose education and naloxone distribution and medications for opioid use disorder delivery by race/ethnicity are well documented.^11,12 When HCS community coalitions began to develop action plans, they asked for community-specific data by race/ethnicity. The data infrastructure from HCS permitted the sharing of the community-specific opioid overdose death trends presented here, well in advance of when statewide data from the same period were made publicly available.⁶ These community-specific data were instrumental in informing consideration of an equitable approach to selecting which evidence-based practices and venues to target.

Limitations of this study are potential misclassification of cause of death and race/ethnicity on death certificates and differences in death investigation practices by state. However, we are not aware of contemporaneous classification changes that would explain observed trends. Death counts for New York in 2019 are preliminary and may be revised upward. Data to calculate age-adjusted rates were unavailable; however, a comparison with statewide crude and age-adjusted rates from CDC’s WONDER (Wide-ranging ONline Data for Epidemiologic Research) produced similar estimates (Appendix).

PUBLIC HEALTH IMPLICATIONS

These data add to the evidence of worsening disparities in opioid overdose deaths by race/ethnicity. In the context of HCS, these data highlight the importance of timely, local data to inform an equitable approach for developing community-tailored strategies to reduce opioid overdose deaths. An antiracist public health approach that explicitly examines the role of racism is urgently needed in research, public health, and policy approaches to address the crisis of opioid-related harms.

ACKNOWLEDGMENTS

This research was supported by the National Institutes of Health (NIH) through the Helping to End Addiction Long-term (HEAL) Initiative (awards UM1DA049406, UM1DA049412, UM1DA049415, UM1DA049417, and UM1DA049394).

We would like to acknowledge the support for this study from the following agencies: Kentucky Office of Vital Statistics, Kentucky Cabinet for Health and Family Services, New York State Department of Health (NYSDOH), NYSDOH Public Health Information Group, NYS Bureau of Vital Records, RecoveryOhio, the Ohio Department of Health, the Ohio Department of Administrative Services (InnovateOhio Platform), the Massachusetts Department of Public Health, and the Biostatistics Epidemiology Data Analytics Center at Boston University.

We also would like to thank the following colleagues and collaborators for their support of the study: Sharon Coleman, Trang Nguyen, Vivian Nwudu, Aimee Mack, Stephanie Mack, Yali Meng, and Greg Patts.

Note. The content of this brief is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or its HEAL Initiative.

CONFLICTS OF INTEREST

M. R. Larochelle received consulting funds for research on opioid use disorder treatment pathways paid to his institution from OptumLabs. No other authors have disclosures to report.

HUMAN PARTICIPANT PROTECTION

This study protocol (Pro00038088) was approved by Advarra, the HCS single institutional review board.

Summary

Opioid overdose mortality in the United States continues to rise, reaching unprecedented levels in 2019. While non-Hispanic White individuals were disproportionately affected in the initial wave of prescription opioid deaths, recent increases driven by heroin and fentanyl have disproportionately impacted non-Hispanic Black and Hispanic individuals. Existing racial inequities within US drug policy, such as harsher penalties for crack cocaine (more commonly used by Black individuals) compared to powder cocaine (more frequently used by non-Hispanic White individuals), exacerbate this disparity. Conversely, the increase in opioid overdose deaths among non-Hispanic White individuals coincided with a transition toward a public health approach prioritizing compassion and treatment.

Methodology

The Helping to End Addiction Long-term Communities Study (HCS), a large-scale community engagement intervention, aimed to reduce opioid overdose deaths. Utilizing death certificate data from four states, researchers analyzed opioid overdose death rates by race/ethnicity from 2018 to 2019. Data analysis employed Poisson regression with the logarithm of population as an offset variable to assess the significance of changes in opioid overdose death rates across racial/ethnic groups and years. Rate ratios (RR) and ratios of rate ratios (RRR) were calculated to compare changes in rates among different racial/ethnic groups relative to non-Hispanic White individuals.

Results

Across 67 HCS communities, the overall opioid overdose death rate showed no statistically significant change from 2018 to 2019. However, a significant 38% increase was observed among non-Hispanic Black individuals. This increase was statistically significant in Kentucky and Ohio, with non-significant increases noted in Massachusetts. New York showed a statistically significant decrease in overdose deaths among non-Hispanic White individuals, alongside no significant change for non-Hispanic Black individuals. Compared to non-Hispanic White individuals, a significantly increasing trend in opioid overdose deaths was observed among non-Hispanic Black individuals across all HCS communities.

Discussion

The study findings reveal persistent and widening disparities in opioid overdose death trends by race/ethnicity. These data underscore the need for an antiracist public health approach addressing systemic racism in policy, practice, and research. The HCS, committed to equity, is actively working to expand evidence-based interventions, including overdose education, naloxone distribution, and medication for opioid use disorder. The availability of timely, community-specific data within HCS proved crucial in informing equitable strategies for intervention. Study limitations include potential misclassification of cause of death and race/ethnicity on death certificates and variations in death investigation methods across states.

Public Health Implications

The study's findings reinforce the worsening disparities in opioid overdose deaths by race/ethnicity. The timely provision of local data is critical in developing targeted and equitable strategies for reducing opioid overdose mortality. An antiracist approach within public health, research, and policy is urgently needed to effectively address the opioid crisis and its disproportionate impact on certain racial/ethnic groups.

Summary

Opioid overdose deaths in the United States reached a record high in 2019. While non-Hispanic White individuals were disproportionately affected in earlier phases of the crisis, recent increases linked to heroin and fentanyl disproportionately impact non-Hispanic Black and Hispanic populations. These disparities highlight existing inequities within US drug policies.

Methods

Researchers analyzed opioid overdose death data from 2018 to 2019 across 67 communities participating in the Helping to End Addiction Long-term Communities (HCS) study. Data were obtained from death certificates and population estimates were derived from the National Center for Health Statistics. Poisson regression analysis was employed to assess changes in opioid overdose death rates by year and race/ethnicity.

Results

The overall opioid overdose death rate showed no significant change between 2018 and 2019. However, a significant 38% increase was observed among non-Hispanic Black individuals. This increase was statistically significant in Kentucky and Ohio, but not in Massachusetts and New York, even though New York exhibited a decline in rates for non-Hispanic White individuals. Compared to non-Hispanic White individuals, the increase in opioid overdose deaths among non-Hispanic Black individuals was statistically significant across all HCS communities.

Discussion

The study's findings underscore persistent racial disparities in opioid overdose deaths. These disparities highlight the need for an anti-racist approach to public health policy and research to address the opioid crisis equitably. The HCS study, with its focus on community-level data, aims to support the development of targeted interventions.

Public Health Implications

The study results emphasize the need for timely, localized data to inform equitable strategies for reducing opioid overdose deaths. An anti-racist approach is crucial to address structural racism contributing to these disparities in both research and policy.

Summary

Opioid overdose deaths are increasing in the US, reaching a record high in 2019. While initially impacting non-Hispanic White individuals, recent increases involving heroin and fentanyl disproportionately affect non-Hispanic Black and Hispanic individuals. Existing racial inequities in drug policy, such as harsher penalties for crack cocaine (more common among Black individuals) compared to powder cocaine (more common among White individuals), contribute to this disparity. A shift towards a public health approach focusing on treatment has been associated with a decrease in overdose deaths among non-Hispanic Whites.

The Helping to End Addiction Long-term Communities Study (HCS)

The HCS is a large-scale study examining community engagement strategies to decrease opioid overdose deaths. Community coalitions involved in the study requested race/ethnicity-specific data to address equity concerns. HCS provided this data more efficiently than publicly available resources, allowing for better informed intervention planning.

Methods

Researchers used death certificate data from four states to analyze opioid overdose deaths in 67 communities involved in HCS. They categorized individuals into four race/ethnicity groups: non-Hispanic White, non-Hispanic Black, Hispanic, and other. Opioid overdose death rates per 100,000 adults were calculated for 2018 and 2019. Statistical methods, including Poisson regression, were used to analyze changes in rates over time and across different racial and ethnic groups.

Results

Overall opioid overdose death rates showed no significant change between 2018 and 2019. However, a 38% increase was observed among non-Hispanic Black individuals. This increase was statistically significant in Kentucky and Ohio, and showed a non-significant increase in Massachusetts. New York showed no significant change for non-Hispanic Black individuals, but a decrease among non-Hispanic White individuals. Compared to non-Hispanic Whites, non-Hispanic Black individuals experienced a significantly higher increase in overdose deaths.

Discussion

While overall rates remained relatively stable, significant racial disparities emerged, particularly the substantial increase among non-Hispanic Black individuals. These findings align with previous research highlighting widening disparities. Experts call for an anti-racist approach to address structural racism impacting opioid overdose deaths. HCS aims to implement evidence-based practices, such as naloxone distribution and medication-assisted treatment, while actively pursuing equity in its interventions. Community-specific data proved crucial in developing tailored strategies. Limitations include potential misclassification in death certificates and variations in death investigation practices.

Public Health Implications

The study results reinforce the need for timely, local data to design equitable strategies to reduce opioid overdose deaths. An anti-racist approach is essential to tackle structural racism affecting the opioid crisis.

Summary

Lots of people are dying from opioid overdoses in the US. In 2019, it was a record high. At first, mostly white people died from prescription opioid pills. But now, more Black and Hispanic people are dying from heroin and fentanyl. This is because of unfairness in how the law deals with drugs.

The Helping to End Addiction Long-term Communities Study (HCS)

Scientists are trying to stop these deaths. They're doing a big study in four states: Kentucky, Massachusetts, New York, and Ohio. They looked at who was dying from opioid overdoses to help.

How the Study Worked

Scientists looked at death records to see how many people died from opioid overdoses and what race they were. They used these numbers to understand the problem better.

What They Found

Overall, the number of deaths stayed about the same between 2018 and 2019. But, something important happened. There was a big increase (38%) in deaths among Black people. This wasn't the case for other groups.

What it Means

This shows that some groups of people are more affected by opioid overdoses than others. The study shows how important it is to have local information about overdoses so scientists and communities can plan to help people. They need to fix the unfairness in how they fight opioid overdoses.