Weekend Reads: Overdose Death Disparities

by Kevin Schofield

It certainly feels like all the recent news has been bad. Here at Weekend Reads, we don't shy away from piling on, so this week, we're tackling one of the least happy news sources out there: the Centers for Disease Control and Prevention's "Morbidity and Mortality Weekly Report," or MMWR. Each week, the CDC does a deep dive into U.S. mortality statistics — how Americans die — to try to provide some insights into what we can be doing to prevent unnecessary deaths.

This week's report highlights an alarming change in U.S. drug overdose deaths in 2020. We all know that it was a super-tough year: Many of us lost friends and family to COVID-19, isolated for months at home, sanitized everything within reach, and feared for our jobs, homes, and economic security. But on top of all that, drug overdose deaths increased by 30% in 2020. In part, that is due to the increased production of fentanyl (and even more dangerous knockoffs), and perhaps the increased isolation and despair many of us felt because of the changes brought on by the COVID pandemic. But looking deeper at the statistics suggests there was a lot more going on that we don't fully comprehend.

Not surprisingly, overdose deaths were higher in areas with greater income inequity. But the racial disparities are even more significant: Among Black Americans, the overdose death rate increased by a startling 44%. Among Black people ages 15—​​24, the increase was 86%, and the rate among Black males over age 65 was seven times higher than for white males of the same age.

To understand why this is so shocking, it's important to understand that illicit drug use among Black Americans is not appreciably higher than among white Americans, nor is there a big difference between the rates of substance use disorder. In fact, in 2019, their rates of drug overdose deaths were nearly identical as well (25 to 27 per 100,000 persons); but in 2020, the overdose death rate rose 24% for white people and 44% for Black people — a huge divergence.

To further confuse matters, the CDC researchers discovered that both the increase in overdose deaths and the racial disparities were greatest in locations where opioid treatment programs are most available. Likewise, they also found the highest rate and greatest disparities where mental health provider availability was greatest. This is truly baffling. First, we would naturally assume that having available treatment facilities would prevent overdose deaths by reducing the number of people abusing drugs. Second, even if substance abuse and mental health treatment resources existed but barriers made them inaccessible to Black people, we would expect to find that they made no difference at all — that the rate of overdose deaths was the same between the places where treatment resources didn't exist at all and the places where they existed but couldn't be accessed. Instead, the researchers found that overdose deaths were even higher for Black people in the places where the treatment resources existed. Now, we need to be clear that this is a correlation and probably not a cause-effect relationship: No one is suggesting that the existence of treatment services actually caused an increase in overdose deaths among Black people. More likely, both of these correlate to some other factor; for example, larger urban areas are more likely to have treatment facilities than suburban and rural regions, and it may be that more dangerous fentanyl knockoffs are being distributed into urban areas. But at this point, that's all speculation.

Why might these disparities exist? It could be one or a combination of reasons. As I suggested above, different, more dangerous illicit drugs may be sold into the Black community. There could be barriers to access to medical help for the Black community: They could be in the wrong locations; medical help could be too costly or not accept the insurance policies Black people are most able to obtain; there could be explicitly racist policies that prevent Black people from being accepted into the programs; the Black community might distrust the providers; there might be a greater stigma within certain racial communities for those seeking treatment; the Black community may simply not be aware of the existence of the services; or the service providers may not be able to provide culturally competent treatment services to Black communities. Or, it might have little to do with prevention and substance abuse disorder prevention, and more to do with emergency services: Is emergency treatment with naloxone more immediately available in white communities than in Black ones?

With that all said, we have a lot of questions and a few hypotheses, but we really don't understand what's going on here. And that's a problem with this kind of quantitative, data-driven research done in isolation: It can be like looking for the proverbial needle in a haystack. There probably is a survey that would tell us why this is happening, but we have no idea what the right survey questions are to ask. This kind of problem screams for qualitative research studies, the natural complement to quantitative research. Instead of running surveys and analyzing large data sets, qualitative researchers go out into the field, interview people, and listen to their stories. They then try to find the commonalities and patterns in the individual stories that transform them from anecdotes into patterns — and from there into new hypotheses that can be tested by quantitative research.

In this case, a qualitative researcher might interview the friends and families of people who have died from overdose deaths, as well as individuals who are at high risk from overdosing themselves. Also, the staff of crime labs who analyze illicit drugs taken off the streets, and health care professionals who work with individuals at high risk of overdoses. It can be slow, difficult, painstaking work, and it often requires months of carefully building a level of trust with individuals who have learned to distrust a system that has repeatedly failed them.

Good social science research is a combination of quantitative and qualitative research, often in a cycle: Qualitative research poses a hypothesis that can be verified through quantitative research, which then often raises a new set of questions that can be best explored through more qualitative research. Over time, our understanding of the problems, and the potential solutions, expands.

The explosion in drug overdose deaths in 2020 is an enormous problem, but we don't yet know enough about its root causes to solve it. For example, it's easy to suggest that we should fund the expansion of substance abuse treatment programs in response, and generally speaking, we should do that anyway: Overdose deaths aside, there is still a far greater need for treatment services than is currently available. But the evidence so far suggests that simply adding treatment facilities won't prevent overdose deaths: There is another dynamic at play, still beyond our comprehension, that is driving the increase in deaths. Before we jump to solutions, we need to better understand what is really going on.

Drug Overdose Deaths, By Selected Sociodemographic and Social Determinants of Health Characteristics — 25 States and the District of Columbia, 2019-2020

Featured Image: Graphic via CDC Vital Signs, used with permission. Use of CDC materials does not constitute its endorsement or recommendation by the U.S. Government, Department of Health and Human Services, or Centers for Disease Control and Prevention; CDC materials are available on the CDC website free of charge.