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).
TABLE 1
Opioid-involved overdose death rates and synthetic opioid–involved overdose death
rates* among adults aged ≥18 years, by urbanization level,
†
race/ethnicity,
§
and age group — National Vital Statistics System, United States, 2015–2017
Urbanization, Race/Ethnicity, Age Group (yrs)
Opioid-involved overdose deaths
Opioid-involved overdose deaths involving synthetic opioids
2015
no. (rate)
2016
no. (rate)
2017
no. (rate)
Absolute rate change¶
% Rate change¶
2015
no. (rate)
2016
no. (rate)
2017
no. (rate)
Absolute rate change¶
% Rate change¶
Large central metro
Black, overall
1,518 (11.8)
2,503 (19.3)
3,161 (24.0)
12.2**
103**
464 (3.6)
1,430 (11.0)
2,186 (16.6)
13.0**
361**
18–24
68 (3.6)
112 (6.0)
113 (6.2)
2.6**
72**
23 (1.2)
54 (2.9)
80 (4.4)
3.2**
267**
25–34
225 (8.6)
368 (13.6)
462 (16.5)
7.9**
92**
79 (3.0)
221 (8.1)
325 (11.6)
8.6**
287**
35–44
255 (11.5)
417 (18.9)
532 (23.9)
12.4**
108**
71 (3.2)
231 (10.5)
354 (15.9)
12.7**
397**
45–54
437 (19.3)
730 (32.5)
934 (41.9)
22.6**
117**
130 (5.7)
451 (20.1)
654 (29.4)
23.7**
416**
55–64
437 (21.8)
706 (34.6)
885 (42.7)
20.9**
96**
139 (6.9)
388 (19.0)
619 (29.8)
22.9**
332**
≥65
96 (5.2)
170 (8.8)
235 (11.6)
6.4**
123**
22 (1.2)
85 (4.4)
154 (7.6)
6.4**
533**
White, overall
6,636 (18.2)
8,251 (22.6)
8,989 (24.6)
6.4**
35**
1,743 (4.7)
3,633 (9.9)
5,038 (13.7)
9.0**
192**
18–24
591 (16.6)
721 (20.7)
703 (20.5)
3.9**
24**
176 (4.9)
324 (9.3)
421 (12.3)
7.4**
149**
25–34
1,736 (24.8)
2,271 (32.2)
2,484 (35.2)
10.4**
42**
531 (7.6)
1,160 (16.4)
1,560 (22.1)
14.5**
191**
35–44
1,360 (24.2)
1,812 (32.4)
2,039 (36.3)
12.1**
50**
378 (6.7)
902 (16.1)
1,253 (22.3)
15.6**
232**
45–54
1,503 (24.1)
1,768 (29.0)
1,908 (32.1)
8.0**
33**
362 (5.8)
726 (11.9)
1,034 (17.4)
11.6**
199**
55–64
1,156 (18.2)
1,369 (21.5)
1,462 (23.0)
4.8**
26**
239 (3.8)
447 (7.0)
657 (10.3)
6.5**
174**
≥65
290 (3.8)
310 (3.9)
393 (4.8)
1.0**
26**
57 (0.7)
74 (0.9)
113 (1.4)
0.7**
100**
Hispanic, overall††
1,176 (6.2)
1,674 (8.8)
1,901 (9.7)
3.5**
57**
238 (1.3)
766 (4.0)
1,058 (5.4)
4.2**
350**
18–24
152 (4.9)
202 (6.5)
234 (7.6)
2.7**
55**
26 (0.8)
82 (2.7)
132 (4.3)
3.5**
438**
25–34
297 (6.8)
440 (9.9)
512 (11.2)
4.4**
65**
68 (1.5)
203 (4.6)
289 (6.3)
4.8**
320**
35–44
287 (7.2)
419 (10.5)
458 (11.3)
4.1**
57**
58 (1.5)
212 (5.3)
271 (6.7)
5.2**
347**
45–54
256 (7.8)
360 (10.8)
420 (12.3)
4.5**
58**
54 (1.7)
173 (5.2)
235 (6.9)
5.2**
306**
55–64
151 (7.0)
219 (9.8)
223 (9.5)
2.5**
36**
26 (1.2)
90 (4.0)
106 (4.5)
3.3**
275**
≥65
33 (1.7)
34 (1.7)
54 (2.5)
0.8
47
—§§
—
25 (1.2)
—
—
Large fringe metro
Black, overall
519 (7.2)
906 (12.3)
1,086 (14.4)
7.2**
100**
179 (2.5)
499 (6.8)
812 (10.8)
8.3**
332**
18–24
48 (4.4)
87 (8.1)
88 (8.1)
3.7**
84**
20 (1.8)
56 (5.2)
62 (5.7)
3.9**
217**
25–34
102 (7.3)
220 (15.3)
273 (18.2)
10.9**
149**
44 (3.2)
130 (9.0)
205 (13.7)
10.5**
328**
35–44
132 (9.9)
193 (14.4)
249 (18.2)
8.3**
84**
47 (3.5)
108 (8.0)
197 (14.4)
10.9**
311**
45–54
127 (9.3)
232 (16.8)
258 (18.4)
9.1**
98**
36 (2.6)
118 (8.5)
184 (13.1)
10.5**
404**
55–64
99 (9.2)
140 (12.5)
184 (15.8)
6.6**
72**
30 (2.8)
71 (6.3)
137 (11.7)
8.9**
318**
≥65
11 (—)
34 (3.4)
34 (3.3)
—
—
—
16 (—)
27 (2.6)
—
—
White, overall
7,561 (17.8)
10,179 (23.8)
11,442 (26.7)
8.9**
50**
2,594 (6.1)
5,292 (12.4)
7,486 (17.5)
11.4**
187**
18–24
801 (18.5)
1,106 (25.8)
1,097 (25.9)
7.4**
40**
303 (7.0)
620 (14.5)
778 (18.4)
11.4**
163**
25–34
2,283 (36.9)
3,177 (50.9)
3,658 (58.3)
21.4**
58**
901 (14.6)
1,887 (30.3)
2,666 (42.5)
27.9**
191**
35–44
1,738 (26.9)
2,392 (37.5)
2,699 (42.4)
15.5**
58**
628 (9.7)
1,318 (20.7)
1,874 (29.4)
19.7**
203**
45–54
1,644 (20.2)
2,009 (25.1)
2,274 (29.2)
9.0**
45**
501 (6.1)
925 (11.6)
1,363 (17.5)
11.4**
187**
55–64
911 (11.4)
1,260 (15.6)
1,433 (17.6)
6.2**
54**
223 (2.8)
475 (5.9)
701 (8.6)
5.8**
207**
≥65
184 (1.9)
235 (2.4)
281 (2.8)
0.9**
47**
38 (0.4)
67 (0.7)
104 (1.0)
0.6**
150**
Hispanic, overall††
423 (5.7)
674 (8.9)
790 (10.0)
4.3**
75**
123 (1.7)
362 (4.8)
531 (6.7)
5.0**
294**
18–24
65 (5.2)
94 (7.5)
95 (7.4)
2.2**
42**
21 (1.7)
48 (3.8)
61 (4.7)
3.0**
177**
25–34
128 (7.5)
214 (12.4)
243 (13.6)
6.1**
81**
44 (2.6)
131 (7.6)
165 (9.2)
6.6**
254**
35–44
119 (7.0)
194 (11.2)
210 (11.7)
4.7**
67**
33 (1.9)
106 (6.1)
149 (8.3)
6.4**
337**
45–54
71 (5.4)
129 (9.5)
157 (11.1)
5.7**
106**
20 (1.5)
58 (4.3)
114 (8.0)
6.5**
433**
55–64
33 (4.1)
37 (4.4)
73 (8.1)
4.0**
98**
—
19 (—)
37 (4.1)
—
—
≥65
—
—
12 (—)
—
—
—
—
—
—
—
Medium and small metro
Black, overall
553 (7.3)
776 (10.1)
1,036 (13.3)
6.0**
82**
199 (2.6)
387 (5.0)
698 (8.9)
6.3**
242**
18–24
36 (2.6)
57 (4.2)
83 (6.2)
3.6**
139**
21 (1.5)
27 (2.0)
54 (4.0)
2.5**
167**
25–34
111 (7.2)
183 (11.6)
231 (14.2)
7.0**
97**
39 (2.5)
99 (6.3)
176 (10.8)
8.3**
332**
35–44
146 (11.4)
193 (15.0)
267 (20.5)
9.1**
80**
55 (4.3)
100 (7.8)
186 (14.3)
10.0**
233**
45–54
139 (11.0)
154 (12.2)
219 (17.5)
6.5**
59**
48 (3.8)
78 (6.2)
149 (11.9)
8.1**
213**
55–64
99 (8.7)
153 (13.2)
187 (15.8)
7.1**
82**
30 (2.6)
72 (6.2)
110 (9.3)
6.7**
258**
≥65
22 (2.2)
36 (3.4)
49 (4.4)
2.2**
100**
—
11 (—)
23 (2.1)
—
—
White, overall
8,794 (16.4)
10,530 (19.6)
11,767 (21.9)
5.5**
34**
2,547 (4.8)
4,449 (8.3)
6,803 (12.6)
7.8**
163**
18–24
757 (11.7)
943 (14.9)
960 (15.4)
3.7**
32**
260 (4.0)
433 (6.8)
634 (10.2)
6.2**
155**
25–34
2,270 (27.7)
2,963 (35.9)
3,324 (40.2)
12.5**
45**
772 (9.4)
1,454 (17.6)
2,203 (26.6)
17.2**
183**
35–44
2,042 (26.9)
2,552 (33.9)
2,892 (38.3)
11.4**
42**
634 (8.4)
1,188 (15.8)
1,816 (24.1)
15.7**
187**
45–54
2,032 (22.6)
2,228 (25.2)
2,475 (28.7)
6.1**
27**
530 (5.9)
867 (9.8)
1,326 (15.4)
9.5**
161**
55–64
1,349 (14.0)
1,450 (14.9)
1,706 (17.5)
3.5**
25**
292 (3.0)
415 (4.3)
733 (7.5)
4.5**
150**
≥65
344 (2.7)
394 (3.0)
410 (3.1)
0.4
15
59 (0.5)
92 (0.7)
91 (0.7)
0.2**
40**
Hispanic, overall††
709 (7.3)
870 (8.8)
1,012 (9.9)
2.6**
36**
127 (1.3)
321 (3.2)
485 (4.7)
3.4**
262**
18–24
78 (4.2)
110 (5.9)
111 (5.8)
1.6**
38**
20 (1.1)
40 (2.1)
59 (3.1)
2.0**
182**
25–34
196 (8.6)
250 (10.8)
298 (12.5)
3.9**
45**
33 (1.4)
88 (3.8)
159 (6.7)
5.3**
379**
35–44
184 (9.2)
231 (11.4)
270 (12.9)
3.7**
40**
37 (1.9)
103 (5.1)
138 (6.6)
4.7**
247**
45–54
159 (10.2)
166 (10.4)
199 (12.1)
1.9
19
29 (1.9)
57 (3.6)
87 (5.3)
3.4**
179**
55–64
77 (7.3)
93 (8.4)
117 (10.1)
2.8**
39**
—
29 (2.6)
38 (3.3)
—
—
≥65
15 (—)
20 (2.0)
17 (—)
—
—
—
—
—
—
—
* Deaths were classified using the International Classification of Diseases, Tenth
Revision (ICD-10). Opioid-involved overdose deaths were identified using underlying
cause-of-death codes X40–44, X60–64, X85, and Y10–14. Among deaths with overdose as
the underlying cause, the type of drug involved in the overdose death was 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 (T40.4). Totals
for deaths by category might involve more than one drug other than synthetic opioids.
Rates displayed are age-specific crude rates per 100,000 persons.
† Based on the 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. Large fringe metro: counties in the MSAs of ≥1 million population that did not
qualify as large central metro counties. Medium metro: counties in MSAs of populations
of 250,000–999,999. Small metro: counties in MSAs of populations <250,000. Because
of low numbers of deaths and rate suppression for key populations, micropolitan areas
(nonmetropolitan counties) and noncore areas (counties that did not qualify as micropolitan)
were not included in this analysis.
§ Blacks and whites are non-Hispanic; Hispanic persons can be of any race.
¶ Absolute rate change is the difference between the 2015 and 2017 rates. Percent
change in rate is calculated as the absolute rate change divided by the 2015 rate,
multiplied by 100. Statistical significance was determined using nonoverlapping 95%
confidence intervals (CIs) based on the gamma method if the number of deaths was <100
in 2015 and 2017, and z-tests were used if the number of deaths was ≥100 in 2015 and
2017. Percent changes were rounded to the nearest whole number. The method of comparing
CIs is a conservative method for statistical significance, and caution should be used
when interpreting a nonsignificant difference when the lower and upper bounds being
compared only slightly overlap.
** p<0.05 using z-tests when deaths were ≥100 or when deaths were <100; nonoverlapping
95% CIs based on a gamma distribution.
†† 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.
§§ Dashes indicate that result is suppressed because <10 deaths, and rates based on
<20 deaths are considered unreliable. Absolute and percent changes in rates cannot
be calculated for these values.
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.
TABLE 2
Percentage of opioid-involved overdose deaths* involving synthetic opioids among adults
aged ≥18 years, by urbanization level, age group, and race/ethnicity, — National Vital
Statistics System, United States, 2015–2017
Urbanization level†
Age group (yrs)
Race/Ethnicity§,¶
Year, %
2015
2016
2017
% Increase, 2015–2017**,††
Large central metro
All
Black
30.6
57.1
69.2
126
White
26.1
44.0
56.0
115
Hispanic
20.2
45.8
55.7
175
18–24
Black
33.8
48.2
70.8
109
White
29.8
44.9
59.9
101
Hispanic
17.1
40.6
56.4
230
25–34
Black
35.1
60.1
70.3
100
White
30.6
51.1
62.8
105
Hispanic
22.9
46.1
56.4
147
35–44
Black
27.8
55.4
66.5
139
White
27.8
49.8
61.5
121
Hispanic
20.2
50.6
59.2
193
45–54
Black
29.7
61.8
70.0
135
White
24.1
41.1
54.2
125
Hispanic
21.1
48.1
56.0
165
55–64
Black
31.8
55.0
69.9
120
White
20.7
32.7
44.9
117
Hispanic
17.2
41.1
47.5
176
≥65
Black
22.9
50.0
65.5
186
White
19.7
23.9
28.8
46
Hispanic
—§§
—
46.3
—
Large fringe metro
All
Black
34.5
55.1
74.8
117
White
34.3
52.0
65.4
91
Hispanic
29.1
53.7
67.2
131
18–24
Black
41.7
64.4
70.5
69
White
37.8
56.1
70.9
88
Hispanic
32.3
51.1
64.2
99
25–34
Black
43.1
59.1
75.1
74
White
39.5
59.4
72.9
85
Hispanic
34.4
61.2
67.9
98
35–44
Black
35.6
56.0
79.1
122
White
36.1
55.1
69.4
92
Hispanic
27.7
54.6
71.0
156
45–54
Black
28.3
50.9
71.3
152
White
30.5
46.0
59.9
97
Hispanic
28.2
45.0
72.6
158
55–64
Black
30.3
50.7
74.5
146
White
24.5
37.7
48.9
100
Hispanic
—
—
50.7
—
≥65
Black
—
—
79.4
—
White
20.7
28.5
37.0
79
Hispanic
—
—
—
—
Medium and small metro
All
Black
36.0
49.9
67.4
87
White
29.0
42.3
57.8
100
Hispanic
17.9
36.9
47.9
168
18–24
Black
58.3
47.4
65.1
12
White
34.3
45.9
66.0
92
Hispanic
25.6
36.4
53.2
108
25–34
Black
35.1
54.1
76.2
117
White
34.0
49.1
66.3
95
Hispanic
16.8
35.2
53.4
217
35–44
Black
37.7
51.8
69.7
85
White
31.0
46.6
62.8
102
Hispanic
20.1
44.6
51.1
154
45–54
Black
34.5
50.6
68.0
97
White
26.1
38.9
53.6
106
Hispanic
18.2
34.3
43.7
140
55–64
Black
30.3
47.1
58.8
94
White
21.6
28.6
43.0
99
Hispanic
—
31.2
32.5
—
≥65
Black
—
—
46.9
—
White
17.2
23.4
22.2
29
Hispanic
—
—
—
—
* Deaths were classified using the International Classification of Diseases, Tenth
Revision (ICD-10). Opioid-involved overdose deaths were identified using underlying
cause-of-death codes X40–44, X60–64, X85, and Y10–14. Among deaths with overdose as
the underlying cause, the type of drug involved in the overdose death was 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 (T40.4). Totals
for deaths by category might involve more than one drug other than synthetic opioids.
The percentage of opioid-involved overdose deaths involving synthetic opioids was
calculated by dividing the number of opioid-involved overdose deaths involving synthetic
opioids by the number of opioid-involved overdose deaths, then multiplying by 100.
† Based on the 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. Large fringe metro: counties in the MSAs of ≥1 million population that did not
qualify as large central metro counties. Medium metro: counties in MSAs of populations
of 250,000–999,999. Small metro: counties in MSAs of populations <250,000. Because
of low numbers of deaths and rate suppression for key populations, micropolitan areas
(nonmetropolitan counties) and noncore areas (counties that did not qualify as micropolitan)
were not included in this analysis.
§ Blacks and whites were non-Hispanic; Hispanics could be of any race.
¶ 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.
** Percentage increase in opioid-involved overdose deaths involving synthetic opioids
was calculated by subtracting the percentage of deaths that involved synthetic opioids
in 2017 from the percentage of deaths involving synthetic opioids in 2015, dividing
this value by the percentage of deaths involving synthetic opioids in 2015, and then
multiplying by 100.
†† Total percent changes were rounded to the nearest whole number.
§§ Dashes indicate that percent change in synthetic opioid involvement in opioid-involved
overdose deaths could not be calculated because of unreliable rates or suppression.
Discussion
Synthetic opioids are driving the recent increases in opioid-involved overdose deaths
in the United States. Previous research has found that synthetic opioids were involved
in nearly 60% of opioid-involved overdose deaths in the United States in 2017 (
1
); this study examines the variation in synthetic opioid involvement in these deaths
among racial/ethnic age groups across different metropolitan areas. For example, in
large central metro areas, among persons aged 45–54 years, synthetic opioids were
involved in 70.0% of all opioid-involved overdose deaths among blacks, 54.2% among
whites, and 56.0% among Hispanics. These findings underscore the changing demographics
and populations affected by the opioid overdose epidemic as the illicit drug supply
continues to evolve.
Consistent with these findings, a recent report by the New York City Department of
Health and Mental Hygiene (
8
) identified high rates of drug overdoses in 2017 involving heroin or fentanyl among
middle-aged and older-aged blacks and Hispanics in a large metropolitan area infiltrated
by IMF in recent years; these rates have largely eclipsed those among whites of the
same age (
9
). The distinct age distributions of opioid-involved overdose deaths between the racial/ethnic
age groups and different metropolitan areas highlight the heterogeneity that exists
among persons who use drugs, illicit drug markets, and risk factors for overdose.
Differences in opioid prescribing rates, underlying rates of opioid and other substance
use disorders, access to substance use disorder treatment, and the proliferation of
IMF in the illicit drug supply might all underlie the unique patterns of opioid-involved
overdose deaths observed in this study. Thus, additional efforts are needed to develop
and implement prevention, treatment, and response strategies that are tailored to
diverse racial/ethnic and age groups within specific community contexts. In addition,
more research is needed to explore the underlying drivers of differing overdose risk
among racial/ethnic age groups across metropolitan areas.
The findings in this report are subject to at least four limitations. First, numbers
and rates of deaths involving specific drugs might be affected by factors related
to death investigations, such as the substances tested for or the circumstances under
which these tests are performed. Second, changes in fentanyl or other synthetic opioid
testing and reporting as well as the percentage of deaths with specific drugs listed
on the death certificate have changed over the study period and might have contributed
to the observed increases in opioid- and synthetic opioid–involved overdose deaths.
††
Third, potential racial or ethnic misclassification might lead to underestimates or
overestimates for certain groups. Finally, because of small numbers of synthetic opioid–involved
overdose deaths among certain racial/ethnic groups, persons aged <18 years, and in
nonmetropolitan areas, data on these populations were not included in this report.
Thus, exploration of how synthetic opioids are affecting these populations is beyond
the scope of this report.
The changing patterns of the opioid overdose epidemic necessitate a rapid, culturally
tailored and multifaceted public health response that appropriately targets and incorporates
the needs of evolving populations at risk, including minority populations that historically
have been regarded as having low opioid-involved overdose death rates. Curbing the
opioid overdose epidemic requires collaborations across all sectors of government,
law enforcement, public health, and communities. This study emphasizes the importance
of data-informed approaches to addressing the evolving needs of communities and highlights
the need for timely data that can be used to effectively guide public health responses.
Prevention and response strategies include public health messaging campaigns to increase
awareness about illicit synthetic opioids in the drug supply, naloxone distribution
that targets both persons who knowingly use opioids and those who might be exposed
to opioids through contamination of other illicit drugs, the expansion of and equitable
access to medication-assisted treatment for opioid use disorder, evidence-based treatment
for other substance use disorders, and recovery support services for persons with
substance use disorders. Importantly, cultural, language, and structural barriers
that minority populations might face should be considered as these interventions are
being developed and implemented.
Summary
What is already known about this topic?
Opioid-involved overdose death rates in the United States differ by demographic and
geographic characteristics. Illicitly manufactured fentanyl and fentanyl analogs have
fueled recent increases in opioid-involved overdose deaths. In 2017, synthetic opioids
were involved in nearly 60% of opioid-involved overdose deaths; however, the level
of involvement by racial/ethnic age groups in metropolitan areas has not been explored.
What is added by this report?
From 2015 to 2017, nearly all racial/ethnic groups and age groups experienced significant
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. The increased involvement of synthetic opioids
in overdose deaths is changing the demographics of the opioid overdose epidemic.
What are the implications for public health practice?
Culturally competent interventions are needed to target populations at risk; these
interventions include increasing awareness about synthetic opioids in the drug supply
and expanding evidence-based interventions, such as naloxone distribution and medication-assisted
treatment.