How fentanyl and COVID-19 pandemic reshaped the racial profile of overdose deaths in US

For as long as statistics about opioid overdose deaths have been collected in the United States, white individuals have been much more likely to die than Black individuals of the same age. With the rapidly increasing rate of fentanyl overdoses in the late 2010s, that trend began to reverse—by the start of the COVID-19 pandemic in 2020, more Black Americans began to die of opioid overdoses and from drug overdoses of any kind, according to researchers at Penn State.

New research from the Penn State College of Health and Human Development examined racial and regional differences in overdose fatalities from 2012-21, capturing the periods preceding and during the COVID-19 pandemic.

In most of the nation, the researchers found that younger Black individuals died of overdose at lower rates than their white counterparts, but older Black individuals—especially men in Midwestern cities—became several times more likely to die of drug overdose than their white counterparts as the COVID-19 pandemic emerged.

The study was published in the American Journal on Addictions.

A group of researchers led by Abenaa Jones, assistant professor of human development and family studies and Ann Atherton Hertzler Early Career Professor in Health and Human Development at Penn State, examined demographic characteristics of the more than half-million people in the United States who died of an overdose between 2012 and 2021.

They used data from the Centers for Disease Control and Prevention’s Wide‐ranging Online Data for Epidemiologic Research (WONDER) “Underlying Causes of Death” file and the Census Bureau to identify the region of residence for every white or Black individual who died of overdose.

“The opioid overdose story in the U.S. was young, white and rural for a long time,” said Joel Segel, associate professor of health policy and administration and co-author of this research. “But the story is changing, especially for older Black adults.”

The overdose death rates increased for both Black and white individuals of all ages during the 10-year study, with younger Black individuals still dying less often than white individuals of overdose. However, overdose death rates increased considerably for older Black individuals from 2012 to 2021. As a result, Black individuals now die of overdose at a higher rate than white individuals in the U.S.

During the pandemic, overdose death rates spiked dramatically across the nation and especially sharply among Black individuals compared to white individuals. In Illinois, Wisconsin and Minnesota—the states with the most pronounced racial differences—a Black person over the age of 55 was around five times more likely to die of a drug overdose than a white person of the same age.

“The most significant finding in our paper was the increase in fatal drug overdoses among Black individuals—particularly older adults in the Northeast, Midwest and West,” said Shashim Waghmare, graduate student in health policy administration at Penn State and co-author of this research.

“This shift highlights the exacerbating impact of COVID-19 on substance use disparities, underlining an urgent need for tailored, culturally competent interventions and resources.”

The other authors agreed that immediate, focused action is needed.

“This is a crisis, and much of the nation is not aware of it,” Jones said.

“Naloxone, known as NARCAN, has reduced deaths among people who use opioids, but if, for example, people who use cocaine do not know they are using opioids—as may be the case when fentanyl is cut into cocaine—then they may not feel the need to carry naloxone. Still, distribution of naloxone to older Black adults might save lives.

“Free distribution of fentanyl test strips might be another way to save lives. Most importantly, researchers and policy makers need to develop a better understanding of this crisis so that we can reverse the trend and save lives.”

The WONDER data did not include information about the reasons for the increases, but the researchers pointed to multiple factors that may be driving the increased deaths among older Black adults.

According to the National Institute on Drug Abuse, there were nearly zero fentanyl-related overdose deaths in the U.S. in 2014, but by 2016, it was the most common drug associated with of overdose fatalities. Fentanyl is powerful enough that it causes a much higher overdose rate than other drugs, according to the researchers. Many people were exposed to fentanyl for the first time when other drugs—notably cocaine—were cut with fentanyl to increase potency at a lower price.

Jones and Segel said that many overdose deaths occurred when people used cocaine contaminated with fentanyl. Their previous research demonstrated that the rate of overdose deaths by people who use cocaine increased much more rapidly than cocaine use.

“We may be witnessing the collision of two separate epidemics,” Jones said. “In the 1980s and 90s, cocaine use was prevalent among Black individuals who lived in urban areas. They may have been using cocaine for years, but now it is leading to overdoses because of the presence of fentanyl.”

The COVID-19 pandemic was another factor that exacerbated overdose rates for all demographic groups across the nation. Between 2012 and 2019, overdose deaths climbed nationwide from a little over 40,000 to about 70,000 per year nationwide.

But in 2020, with the COVID-19 pandemic and attendant lockdowns, overdose deaths jumped to over 90,000. The following year, they passed 100,000 for the first time and have remained at that level—more than double the number of deaths from drug overdoses in 2012.

In addition to racial disparities, the researchers noted striking regional differences in the pattern of overdose deaths. In Western and Midwestern states, Black individuals had lower overdose death rates than white individuals before the pandemic but higher rates since 2020. In Southern states, by contrast, Black individuals had consistently lower drug overdose death rates than their white counterparts at every age.

“There may or may not be lessons in the South that could be applicable in other regions,” said Alexis Santos-Lozada, assistant professor of human development and family studies and co-author of this research.

“To know that would require more research. While the solutions to the overdose crisis may be racially and regionally specific, this is a national problem. We need to raise awareness so that it can be understood and addressed.”