U.S. opioid deaths jump fourfold in 20 years; epidemic shifts to eastern states

The opioid epidemic is no longer concentrated among whites in Appalachian and Midwestern states, according to a new study from Stanford, Harvard and the University of Toronto.

Mathew Kiang

Opioid-related deaths nationwide jumped fourfold in the last two decades, and the epidemic has made major inroads in the eastern states, according to a new study by researchers at the Stanford University School of Medicine, Harvard University and the University of Toronto. 

“Although opioid-related mortality has been stereotyped as a rural, low-income phenomenon concentrated among Appalachian or midwestern states, it has spread rapidly, particularly among the eastern states,” the study said.

The researchers found the highest rates of opioid-related deaths occurred in eight states: Connecticut, Illinois, Indiana, Massachusetts, Maryland, Maine, New Hampshire and Ohio. Two states, Florida and Pennsylvania, had opioid-related mortality rates that were doubling every two years. The mortality rate from opioids has increased the fastest in the District of Columbia, more than tripling every year since 2013, the researchers found.

The study’s findings were published Feb. 22 in JAMA Network Open. Mathew Kiang, ScD, a postdoctoral scholar at Stanford, is the lead author. The senior author is Monica Alexander, PhD, assistant professor of sociology and statistical sciences at the University of Toronto.

‘More potent than they expected’

Synthetic opioid deaths now outnumber heroin deaths, which suggests synthetics, such as as fentanyl, have contaminated the production process of other illegal drugs, like cocaine and methamphetamines, and is no longer limited to heroin, Kiang said.

 “People aren’t aware their drugs are laced and more potent than they expected, putting them at higher risk of overdose,” Kiang said.

 The research, which is based on data from the National Center for Health Statistics and the U.S. Census, suggests the opioid epidemic has evolved as three waves, based on the types of opioids associated with mortality:

  • The first wave of opioid-related deaths, from the 1990s until about 2010, was associated with prescription painkillers.
  • The second wave, from 2010 until recently, was associated with a large increase in heroin-related deaths.
  • The third and current wave, which began around 2013, involves a rapid increase in deaths associated with illicitly manufactured synthetic opioids, such as tramadol and fentanyl.


“The evolution has also seen a wider range of populations being affected, with the spread of the epidemic from rural to urban areas and considerable increases in opioid-related mortality observed in the black population,” the study says.

The Centers for Disease Control and Prevention reports that African-Americans experienced the largest increase in opioid overdose deaths among any racial group from 2016 to 2017, with a 26 percent surge.

“The identification and characterization of opioid ‘hot spots’ — in terms of both high mortality rates and increasing trends in mortality — may allow for better-targeted policies that address the current state of the epidemic and the needs of the population,” the researchers wrote.

States are trying to combat the epidemic by enacting policies, such as restricting the supply of prescription painkillers and expanding treatment and access to the overdose-reversing drug naloxone.

“Treating opioid use disorder should be our top priority to curb the problem,” Kiang said. “Similarly, we have the ability to counteract the effects of an overdose. These lifesaving drugs should be easily accessible and widely available.”

Another Stanford co-author of the work was Sanjay Basu, MD, PhD, assistant professor of medicine and of health research and policy.

The study was supported by the National Institutes of Health (grant DP2MD010478).

Stanford’s departments of Medicine and of Health Research and Policy also supported the study.



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