The Drug Overdose Crisis Has Affected Some Groups and Places More than Others
By Shannon Monnat
How many times have you heard the phrase “addiction doesn’t discriminate”? Although the cliché is technically accurate - no one is immune from developing an addiction - it is also true that drug overdose rates are much higher among some populations and places in the United States than others. My research explores this variation.
In a recent paper, I examined sex, racial/ethnic, age group, and geographic differences in the over 1 million American lives lost to drug overdoses between 1999 and 2020. The first main takeaway from this research is some demographic groups have been more affected than others. Males consistently had higher overdose rates than females, a pattern consistent with higher rates of drug use and higher risk use (such as injecting drugs), among males. However, female overdose rates have increased at a startling clip in recent years, reflecting the need to focus more attention and resources on combating substance use initiation among females. In terms of age group differences, working-age adults (25-64) have much higher overdose rates than younger and older age groups. Although most drug use begins during adolescence and early adulthood, overdose rates are higher in young adulthood and middle age because people tend to increase the amount of drugs they use as their tolerance increases. In terms of racial/ethnic differences, rates are much higher among Whites, American Indians, and Blacks than they are among Hispanics and Asians. Black males have experienced especially large increases in recent years.
Fatal Drug Overdose Rates by County, 2018-2020
Data Source: National Vital Statistics System restricted use files. Rates are age adjusted.
The second takeaway is that some places in the U.S. have borne the brunt of the overdose crisis. Fatal overdose rates have been consistently high in Appalachia and the Industrial Midwest, but in recent years, rates have also increased throughout New England, the mid-Atlantic, the golf coast, and the desert Southwest. Throughout the period I studied, rates remained comparatively low in the Mississippi Delta, most of Texas, and much of the Great Plains. What most of the counties with the highest overdose rates have in common is that they are economically disadvantaged and have generally poor health and high premature mortality. In short, they are places where a large share of the population is suffering.
McDowell County, West Virginia provides a good illustration, as it was one of the canaries in the proverbial coal mine of the contemporary overdose crisis, with overdoses surging there long before the rest of the country was paying any attention to the coming crisis. For decades, McDowell County was the world’s largest coal producer. It was a company town—a place where nearly all housing, stores, and services were owned by the mining company that was also the main employer. When the mines closed, the population plummeted from nearly 100,000 in 1950 to fewer than 19,000 today. As the coal companies moved on, good paying mining jobs were replaced with lower paying service jobs as the main source of employment. But even those have disappeared; Walmart closed its doors 2016. With large shares of the population jobless and hopeless and suffering from untreated physical and psychological pain, pharmaceutical companies like Purdue Pharma targeted their intense marketing and overprescribing of cheap highly addictive opioids in places like McDowell County.
So, what should be done to reduce overdoes in the populations struggling the most? It is instructive to reflect first on what hasn’t worked. Federal and state governments have enacted various policies focused on curbing supply, such as prescribing limits, prescription drug monitoring programs, drug seizures, and mass incarceration. Such efforts have not reduced overdose rates. Despite the fact that overdoses continue to increase in the face of supply-side intervention failures, the federal government continues to double-down, evidenced most recently by the Biden administration’s plan to crack down on fentanyl trafficking. Supply is important, but it does not occur in a vacuum. So long as there is demand for substances, suppliers will find a way to meet that demand, and people with substance use disorders will use whatever substance is available to meet their needs. This is reflected in the fact that while opioids remain the largest contributor to overdoses, overdoses involving methamphetamine and other stimulants have increased dramatically in recent years. Rather than doubling down on proven ineffective supply side interventions, policies must instead focus on a) making drug use as safe as possible for existing users (to reduce overdose deaths in the short term) and b) preventing risky drug use initiation to reduce overdose deaths in the long term.
In the immediate term, harm reduction approaches are essential. These include increasing access to Medication Assisted Therapies, Naloxone (the opioid overdose reversal drug), and fentanyl test strips. But these strategies are tourniquets, and they do not work for non-opioid drugs. Rather than trying to fix problems after they emerge, the U.S. must instead invest in the institutions and systems that will prevent problems from emerging in the first place. Early childhood is a key target period for preventing drug use initiation. Evidence-based programs that link children and parents with schools to promote prosocial skill development and reduce risky behaviors are a good start. Structural interventions are also needed to reinvigorate left-behind communities like McDowell County, WV. The highest rates of drug overdose are in places characterized by the long-term erosion of economic opportunity, family stability, and social institutions. Governments and business leaders must work to increase the availability of and training for secure livable wage jobs, enhance opportunities for upward mobility, and revitalize the country’s diminishing social infrastructure. The need for long-term investments means that policymakers and the public must get comfortable with the idea that the observable impacts of investments may not be instant. This is difficult in a political environment where politicians are constantly working toward reelection, but we did not get into this mess overnight, and we cannot expect that short-term supply-targeted solutions will get us out of it.
Article Details
Demographic and Geographic Variation in Fatal Drug Overdoses in the United States, 1999–2020
Shannon M. Monnat
First published online March 20, 2023
.DOI: 10.1177/00027162231154348
The ANNALS of the American Academy of Political and Social Science
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