Overdose deaths among Black and Indigenous people in the United States surged in 2020, rising at far faster rates than for white people, according to a new analysis from the federal Centers for Disease Control and Prevention (CDC). Disparities were even starker when data were broken down into certain age and gender categories.
In a report released July 19, the CDC examined overdose data from 25 states and the District of Columbia. It notes that a total of 91,799 overdose deaths were recorded nationwide in 2020—a roughly 30 percent overall increase from 2019. “Recent increases in drug overdose deaths were largely driven by illicitly manufactured fentanyl and fentanyl analogs,” states the report. Every single one of these deaths is a tragedy. But the devastation is not evenly distributed.
Black men aged 65 or above died of overdose at a rate almost seven times higher than their white counterparts in 2020.
The CDC found that between 2019-2020, fatal overdose rates increased by 44 percent among non-Hispanic Black people, and by 39 percent among American Indian or Alaska Native people. The increase for white people, still substantial, was significantly lower, at 22 percent.
For Black people in 2020, the age-adjusted overall rate of deaths per 100,000 population stood at 38.9—the highest among the CDC’s racial or ethnic categories. The equivalent figure for American Indian or Alaska Native people was 36.4. For white people, it was 30.7; for Hispanic people, 21.0; and for Asian or Pacific Islander people, a significantly lower 3.3.
But the worst disparities are seen in some of the age and gender breakdowns. In particular, Black men aged 65 or above died of overdose at a rate almost seven times higher than their white counterparts in 2020. And the rate of fatal overdose among young Black people (aged 15-24) nearly doubled in just one year.
The age group most vulnerable to overdose was older among Black people than it was for other demographics: Black people aged 45-65 had the highest fatality rate of any racial and age category, at 77.6 per 100,000. The 25-44 age group was the most vulnerable for all other demographics, with Indigenous people (75.1 deaths per 100,000 population) suffering the highest of these rates.
Among Black people, only 8 percent had received any treatment—the lowest of any demographic.
Looking at health history, the CDC reported that for most of the people who died (77 percent), there was “documented evidence” of substance use disorder (with substances other than alcohol). But very few people (14 percent overall) had received any treatment for SUD. Among Black people, only 8 percent had received any treatment—the lowest of any demographic.
Significantly, there was evidence of drug injection for relatively few people who died (24 percent overall)—a fact that should inform harm reduction provision.
Overdose rates were higher in counties with greater income inequality—the widest gaps between rich and poor. Black and Hispanic residents were even worse affected in these areas. And overdose rates for some racial groups were significantly higher in counties that had more mental health care and substance use treatment providers, raising questions about access and other variables.
“Health disparities in overdose rates continue to worsen, particularly among Black and [American Indian or Alaska Native] persons; social determinants of health, such as income inequality, exacerbate these inequities,” states the report. “Implementation of available, evidence-based, culturally responsive overdose prevention and response efforts that address health disparities impacting disproportionately affected populations are urgently needed.”
To put these disturbing findings in more context, Filter spoke with Sheila Vakharia, PhD, deputy director of the Department of Research and Academic Engagement at the Drug Policy Alliance.
“The dramatic increases among Black and Indigenous folks are incredibly alarming.”
Alexander Lekhtman: What are the most important things to take away from this report?
Sheila Vakharia: The most dramatic findings for me show the persisting and more severe racial disparities in overdose death rates in the US. Largely it seems like numbers went up for all groups, however the dramatic increases among Black and Indigenous folks are incredibly alarming. Some of the more troubling information is stratified by age and gender.
We see these increases going up, yet we continue to double down on so many of the failed approaches—in terms of more enforcement, drug seizures and supply-side intervention. A lot of these communities are incredibly underserved when it comes to getting access to the harm reduction services and evidence-based treatment that could reduce the likelihood of overdose.
Does the study show the impact of drug criminalization on overdose?
One thing that’s a variable we don’t talk about enough is the criminalization of drugs, which impacts communities of color. The closest variable used in this study was recent release from jail, which didn’t have too many dramatic disparities by race.
But I think currently being on probation or parole and having a criminal history are all variables that put communities of color at risk for poorer health outcomes, because it can affect their employment, their ability to get good health insurance, their ability to have stable housing, and all the things a background check can exclude you from.
Why do you think higher overdose rates for some racial groups correlated with counties with more mental health and substance use treatment provision?
It goes to show barriers still remain for access to services. What are the barriers? Is it insurance access, is it cultural competency, the availability, the waitlist?
On the other hand, if people were using these services, are facilities providing evidence-based treatments like methadone or buprenorphine? And are people given a menu of treatment options when it comes to psychosocial treatments? Are they given the choice of cognitive behavioral therapy? Or 12-step facilitation—is that the only way to go?
Are there racist barriers to medications for opioid use disorder?
We actually don’t see huge disparities between Black and white people specifically on access to methadone. However, the studies that do exist do show racial disparities between Black and white patients getting access to buprenorphine.
There’s a seminal study that came out a few years ago that found that among privately insured patients, Black patients were [much] less likely to be prescribed buprenorphine.
“We need to move towards pharmacy-based dispensing for methadone, remove counseling requirements altogether and get rid of the X-waiver.”
What can we do right now to improve things?
We need to think about loosening restrictions on methadone and buprenorphine. We’ve taken steps already because of Covid-19, with greater amounts of take-homes for both drugs—also loosening prescribing regimens and being able to do it via telehealth.
We need to loosen restrictions on these medications, move towards pharmacy-based dispensing for methadone, remove counseling requirements altogether and get rid of the X-waiver.
The CDC’s analysis suggests that across all groups, injection drug use is not so prevalent—and the least so among Black people, with close to 90 percent of those who died not injecting drugs. What does this tell us?
One thing that’s missing from this study but that’s part of a broader trend is that a lot of times in communities of color, especially among Black people, overdose death rates involving stimulant drugs tend to be higher.
Having conversations about safer smoking equipment, teaching people about safer smoking strategies, engaging people around drug checking for stimulant drugs, and not mixing stimulants and opioids, are important factors. Stimulant-involved overdose deaths are not going to be affected by buprenorphine or methadone, for instance.
Dr. Vakharia is a member of the board of directors of The Influence Foundation, which operates Filter. The Influence Foundation previously received a restricted grant from the Drug Policy Alliance to support a Drug War Journalism Diversity Fellowship.