Racial/Ethnic and Age Group Differences in Opioid and Synthetic Opioid–Involved Overdose Deaths Among Adults Aged ≥18 Years in Metropolitan Areas

United States, 2015-2017

Kumiko M. Lippold, PhD; Christopher M. Jones, PharmD; Emily O'Malley Olsen, PhD; Brett P. Giroir, MD

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(43):967-973. 

In This Article

Abstract and Introduction

Introduction

Among the 47,600 opioid-involved overdose deaths in the United States in 2017, 59.8% (28,466) involved synthetic opioids.[1] Since 2013, synthetic opioids, particularly illicitly manufactured fentanyl (IMF), including fentanyl analogs, have been fueling the U.S. overdose epidemic.[1,2] Although initially mixed with heroin, IMF is increasingly being found in supplies of cocaine, methamphetamine, and counterfeit prescription pills, which increases the number of populations at risk for an opioid-involved overdose.[3,4] With the proliferation of IMF, opioid-involved overdose deaths have increased among minority populations including non-Hispanic blacks (blacks) and Hispanics, groups that have historically had low opioid-involved overdose death rates.[5] In addition, metropolitan areas have experienced sharp increases in drug and opioid-involved overdose deaths since 2013.[6,7] This study analyzed changes in overdose death rates involving any opioid and synthetic opioids among persons aged ≥18 years during 2015–2017, by age and race/ethnicity across metropolitan areas. Nearly all racial/ethnic groups and age groups experienced increases in opioid-involved and synthetic opioid–involved overdose death rates, particularly blacks aged 45–54 years (from 19.3 to 41.9 per 100,000) and 55–64 years (from 21.8 to 42.7) in large central metro areas and non-Hispanic whites (whites) aged 25–34 years (from 36.9 to 58.3) in large fringe metro areas. Comprehensive and culturally tailored interventions are needed to address the rise in drug overdose deaths in all populations, including prevention strategies that address the risk factors for substance use across each racial/ethnic group, public health messaging to increase awareness about synthetic opioids in the drug supply, expansion of naloxone distribution for overdose reversal, and increased access to medication-assisted treatment.

Drug overdose deaths were identified in the National Vital Statistics System multiple cause-of-death mortality files,* using the International Classification of Diseases, Tenth Revision (ICD-10), underlying cause-of-death codes X40–44 (unintentional), X60–64 (suicide), X85 (homicide), or Y10–Y14 (undetermined intent). These underlying cause-of-death codes identify deaths caused by acute toxicity from drugs rather than chronic exposure or adverse effects, including all intents. Among deaths with these underlying cause-of-death codes, the type of opioid involved in the drug overdose death is indicated by the following ICD-10 multiple cause-of-death codes: any opioid (T40.0, T40.1, T40.2, T40.3, T40.4, or T40.6) and synthetic opioids other than methadone (e.g., fentanyl, fentanyl analogs, and tramadol) (T40.4). Some deaths involved more than one type of opioid; these deaths were included in counts and rates for each subcategory. Thus, categories were not mutually exclusive.

Crude death rates per 100,000 population for overdose deaths involving any opioid and those involving synthetic opioids were examined for 2015–2017 by age group stratified by race/ethnicity within metropolitan areas (large central metro, large fringe metro, and medium/small metro). Metropolitan area was based on the 2013 urbanization classification scheme. Analyses comparing absolute and percentage changes in death rates from 2015 to 2017 used z-tests when deaths were ≥100 and nonoverlapping 95% confidence intervals based on a gamma distribution when deaths were <100.§ Data on synthetic opioid-involved overdose deaths by race/ethnicity and age group within nonmetropolitan areas as well as deaths among non-Hispanic American Indian/Alaska Natives, non-Hispanic Asian Americans, and persons aged <18 years were almost universally suppressed because of small numbers of deaths; thus, they were not included in the analysis.

From 2015 to 2017, death rates for drug overdoses involving any opioid and synthetic opioids increased across all racial/ethnic groups in each metropolitan area (Table 1). In large central metro areas, blacks experienced the largest absolute and percentage increases in rates of drug overdose deaths involving any opioid or synthetic opioids, with rates for deaths involving any opioid increasing 103% (from 11.8 to 24.0 per 100,000, absolute increase of 12.2), and for deaths involving synthetic opioids increasing 361% (from 3.6 to 16.6; absolute increase of 13.0). In large fringe metro areas, whites experienced the largest absolute increases rates of overdose deaths involving any opioid (from 17.8 to 26.7, absolute increase of 8.9) and those involving synthetic opioids (from 6.1 to 17.5, absolute increase of 11.4); blacks experienced the largest percentage change in drug overdose death rates involving any opioid (100%, from 7.2 to 14.4) and for overdose deaths involving synthetic opioids (332%, from 2.5 to 10.8). In medium/small metro areas, for overdose deaths involving any opioid, blacks experienced the largest percentage (82%) and absolute increase (6.0; from 7.3 to 13.3) in rates; whites had the largest absolute increase in rates of overdose deaths involving synthetic opioids (from 4.8 to 12.6, absolute increase of 7.8), and Hispanics** had the largest percentage increase in rates of drug overdose deaths involving synthetic opioids (262%, from 1.3 to 4.7).

Examining death rates for drug overdose deaths involving any opioid or synthetic opioids by racial/ethnic age groups in large central metro areas found that the highest drug overdose death rates involving any opioid (42.7) and synthetic opioids (29.8) in 2017 were among blacks aged 55–64 years (Table 1). From 2015 to 2017, blacks aged 45–54 years in large central metro areas experienced the largest absolute increase in death rates involving any opioid (from 19.3 to 41.9, absolute increase of 22.6) and synthetic opioids (from 5.7 to 29.4, absolute increase of 23.7), and blacks aged ≥65 years in these areas had the largest percentage increases in rates of drug overdose deaths involving any opioid (123%; from 5.2 to 11.6) and synthetic opioids (533%; from 1.2 to 7.6).

Among racial/ethnic age groups in large fringe metro areas, in 2017, the highest rates of drug overdose deaths involving any opioid (58.3) and synthetic opioids (42.5) were in whites aged 25–34 years (Table 1); this group also experienced the largest absolute increases in death rates involving any opioid (from 36.9 to 58.3; absolute increase of 21.4) and synthetic opioids (from 14.6 to 42.5; absolute increase of 27.9) in these areas from 2015 to 2017. The largest percentage increase in rates of drug overdose deaths involving any opioid in large fringe metro areas from 2015 to 2017 occurred among blacks aged 25–34 years (149%; from 7.3 to 18.2), and the largest percentage increase in overdose death rates involving synthetic opioids was in Hispanics aged 45–54 years (433%; from 1.5 to 8.0).

Among racial/ethnic age groups in medium/small metro areas, in 2017, the highest rates of drug overdose deaths involving any opioid or synthetic opioids were in whites aged 25–34 years (40.2 and 26.6, respectively). This group also experienced the largest absolute increases in drug overdose death rates involving any opioid (from 27.7 to 40.2, absolute increase of 12.5) and synthetic opioids (from 9.4 to 26.6, absolute increase of 17.2) in these areas from 2015 to 2017 (Table 1). From 2015 to 2017, blacks aged 18–24 years experienced the largest percentage increase in opioid-involved overdose death rates (139%; from 2.6 to 6.2); the largest percentage increase in synthetic opioid–involved overdose death rates (379%; from 1.4 to 6.7) occurred among Hispanics aged 25–34 years.

The percentage of all opioid-involved overdose deaths involving synthetic opioids increased from 2015 to 2017 across all racial/ethnic age groups in each metropolitan area category (Table 2). By 2017, the greatest level of synthetic opioid involvement in opioid-involved overdose deaths was among blacks in all metro areas and ranged from 67.4% in medium/small metro areas to 74.8% in large fringe metro areas. Among whites, the percentage of opioid-involved overdose deaths involving synthetic opioids ranged from 56.0% in large central metro areas to 65.4% in large fringe metro areas. Among Hispanics, the percentage of opioid-involved overdose deaths involving synthetic opioids ranged from 47.9% in medium/small metro areas to 67.2% in large fringe metro areas.

* https://www.cdc.gov/nchs/nvss/mortality_public_use_data.htm.
Based on 2013 urbanization classification (https://www.cdc.gov/nchs/data_access/urban_rural.htm). Large central metro: counties in metropolitan statistical areas (MSAs) of ≥1 million population that 1) contain the entire population of the largest principal city of the MSA, or 2) have their entire population contained in the largest principal city of the MSA, or 3) contain at least 250,000 inhabitants of any principal city of the MSA (e.g., District of Columbia and New York County, New York). Large fringe metro: counties in the MSAs of ≥1 million population that did not qualify as large central metro counties (e.g., Baltimore County, Maryland, and Austin County, Texas). Medium metro: counties in MSAs of populations of 250,000–999,999 (e.g., Durham County, North Carolina). Small metro: counties in MSAs of populations <250,000 (e.g., Montgomery County, Virginia). For this study, medium and small metros are combined (medium/small).
§ https://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_03.pdf.
Death counts are suppressed when the result is fewer than 10 death because of confidentiality constraints that aid in the protection of personal privacy and prevent identification.
** Data for Hispanic origin should be interpreted with caution; studies comparing Hispanic origin on death certificates and on census surveys have indicated that reporting on Hispanic ethnicity is inconsistent. https://www.cdc.gov/nchs/data/series/sr_02/sr02_172.pdf.

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