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Clinical Context

The fact that adult life expectancy has declined in the United States since the beginning of the COVID-19 pandemic is highly depressing, if not surprising. Most of the excess mortality during the pandemic is, of course, related to complications of infection with SARS-CoV-2 itself, but is it possible that other causes of mortality are also reducing life expectancy? A study by Faust and colleagues, which was published in the July 6, 2021 issue of JAMA, assessed the epidemiology of causes of excess deaths during the COVID-19 pandemic.^[1]

Researchers used a national databank to find diagnosis codes for different forms of excess deaths, and they compared rates of expected vs actual death. Whereas deaths due to motor vehicle crashes declined in early 2020, this effect was reversed during that summer, yielding no net change overall. In contrast, homicide deaths were elevated by April 2020 and remained elevated through that summer. The rate of suicide actually declined with the onset of the pandemic.

The biggest difference, however, in actual vs expected rates of mortality was recorded for drug overdose. The overall observed-to-expected ratio for this outcome was 1.28 (95% CI: 1.15, 1.44). The burden of drug overdose has never been borne evenly across different communities, and the current study by Han and colleagues examines race/ethnicity as a variable associated with drug overdose during the COVID-19 pandemic.

Study Synopsis and Perspective

Drug overdose deaths rose significantly during the COVID-19 pandemic but more so among Black and American Indian/Alaska Native persons.

The results underscore the "urgency of expanding prevention, treatment, and harm reduction interventions tailored to specific populations, especially American Indian or Alaska Native and Black populations, given long-standing structural racism and inequities in accessing these services," the researchers noted.

The study was published September 1 in JAMA Network Open.^[2]

From February 2020 to August 2021, drug overdose deaths in the United States rose 37%, and these deaths were largely due to synthetic opioids other than methadone -- primarily fentanyl or analogs -- and methamphetamine.

Yet, data are lacking regarding racial and ethnic disparities in overdose death rates.

To investigate, Beth Han, MD, PhD, with the National Institute on Drug Abuse, and colleagues analyzed federal drug overdose death data for individuals aged 15 to 34 years and 35 to 64 years from March 2018 to August 2021.

Among individuals aged 15 to 34 years, from March 2018 to August 2021, overdose death rates involving any drug, fentanyl, and methamphetamine with or without fentanyl, increased overall. For the 6 months from March to August 2021, non-Hispanic American Indian or Alaska Native men had the highest rates overall involving any drug, fentanyl, and methamphetamine without fentanyl, with rates of 42, 30.2, and 6 per 100,000, respectively. The highest rates (per 100,000) of drug overdose deaths involving methamphetamine with fentanyl were for American Indian or Alaska Native men (9.2), women (8), and non-Hispanic White men (6.7).

Among people aged 35 to 64 years, from March to August 2021, overall drug overdose rates (per 100,000) were highest among non-Hispanic Black men (61.2) and American Indian or Alaska Native men (60), and fentanyl-involved death rates were highest among Black men (43.3). Rates involving methamphetamine with fentanyl were highest among American Indian or Alaska Native men (12.6), women (9.4), and White men (9.5). Rates involving methamphetamine without fentanyl were highest among American Indian or Alaska Native men (22.9).

The researchers noted the findings highlight the "urgent need" for education on dangers of methamphetamine and fentanyl.

Expanding access to naloxone, fentanyl test strips, and treatments for substance use disorders to disproportionately affected populations is also critical to help curb disparities in drug overdose deaths, they added.

Limitations of the study are that overdose deaths may be underestimated due to the use of 2021 provisional data and that racial or ethnic identification may be misclassified, especially for American Indian or Alaska Native people.

This study was sponsored by the National Institute on Drug Abuse of the National Institutes of Health and the Centers for Disease Control and Prevention. The authors report no relevant disclosures.

Study Highlights

• Investigators drew study data from the US National Vital Statistics Multiple Cause-of-Death database. Researchers were primarily interested in the race-ethnicity as a variable in mortality due to drug overdose.
• Specifically, researchers examined mortality rates related to any drug overdose as well as from fentanyl and methamphetamine specifically. The study period ran from March 2018 to August 2021.
• Rates of overdose death increased across all racial/ethnic groups in 2020-2021 compared with previous years.
• Among US residents between the ages of 15 and 34 years, the highest rates of death per 100,000 people were recorded among American Indian/Alaska Native men (42 deaths/100,00 people). They were followed by Black and White men.
• American Indian/Alaska Native communities also had the highest rates of overdose due to fentanyl and methamphetamine specifically.
• Rates of overdose death were higher overall for the cohort between the ages of 35 and 64 years vs the 15- to 34-year-old age group.

Figure. Patient Populations with Highest Drug Overdose Rates

• In this older cohort, rates of drug overdose death per 100,000 individuals were highest among Black men (61.2 cases/100,000 people) and American Indian/Alaska Native men (60/100,000).
• Rates of drug death due to fentanyl and methamphetamine among the cohort between the ages of 35 and 64 years were highest among American Indian/Alaska Native men and White men.
• Men had higher rates of drug overdose deaths compared with women regardless of race/ethnicity or study year.

Clinical Implications

• A previous study by Faust and colleagues examined trends in excess death during the COVID-19 pandemic and found that deaths due to motor vehicle crashes were stable overall in 2020. In contrast, homicide deaths were elevated by April 2020 and remained elevated through that summer. The rate of suicide actually declined with the onset of the pandemic, while the biggest difference in actual vs expected deaths occurred with drug overdose.
• The highest rates of fatal drug overdose during the COVID-19 pandemic were experienced by American Indians/Alaska Natives among racial/ethnic groups included in the current study.

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