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Official websites use. Share sensitive information only on official, secure websites. Correspondence: Mathew V. E-mail mkiang mail. The work cannot be changed in any way or used commercially without permission from the journal. Recent research on the US opioid epidemic has focused on the white or total population and has largely been limited to data after However, understanding racial differences in long-term trends by opioid type may contribute to improving interventions. Using multiple cause of death data, we calculated age-standardized opioid mortality rates, by race and opioid type, for the US resident population from to We analyzed trends in mortality rates using joinpoint regression. From to , the long-term trends in opioid-related mortality for Earlier data did not include ethnicity so this is incorrect. It is all black and all white residents in the US. In the first wave, from to the mids, the epidemic affected both populations and was driven by heroin. In the current wave, increases in opioid mortality for both populations have been driven by heroin and synthetic opioids e. Since , the opioid mortality rate has increased fold in the United States, resulting in over 33, deaths in alone, drawing national attention and becoming an important part of the political agenda. In the s and s, the epidemic was driven by prescription opioids 3 , 4 as part of aggressive marketing tactics by the pharmaceutical industry and changing medical standards in diagnosis and treatment of chronic pain. Recent research describes the opioid epidemic as having been initially driven by prescription opioids starting in the mids, followed by a continuing rise in the number of heroin deaths starting in the mids, concurrently fueled by illicitly manufactured synthetic opioids such as fentanyl, starting around To date, this is the longest period of analysis of opioid mortality in the United States, contributing an expanded perspective on trends over time and allowing for the examination of mortality by race and opioid type to understand the factors behind these trends. We used a publicly available microlevel dataset with multiple causes of death derived from all the death certificates collected in the United States by the National Center for Health Statistics from to In addition, up to 20 other contributory causes can be listed on the death certificate. The presence of a drug is not sufficient for the drug to be deemed the underlying cause; therefore, both the underlying and contributory causes must be considered when identifying deaths from drug overdose. Death certificates are coded by the National Center for Health Statistics to produce multiple cause of death data. For —, all opioid overdoses were defined by a combination of specific codes for the underlying cause and at least one relevant contributory cause code. In addition, for a death to be defined as opioid related, it has to include one or more of the following ICD codes: opium T Using the multiple cause of death data, we tabulated deaths from opioid overdose for the total, black, and white resident populations by five-year age groups i. In addition, we tabulated these deaths by type of opioid. Due to the changes in the coding of opioid types from ICD-9 to ICD, we defined three temporally stable opioid categories as a opioid deaths involving heroin, b opioid deaths involving methadone, and c opioid deaths involving an opioid other than but not excluding heroin or methadone. For the ICD years — , we additionally tabulated deaths by type of opioid using the more specific ICD categories defined above. All rates are expressed as the number of deaths per , people and directly age-standardized to the US population. Standard errors for the rates were obtained using a Poisson approximation. We used joinpoint regression to examine trends in the age-standardized rates and rate ratio calculated as described above via the Joinpoint Regression Program version 4. Model fit is evaluated using a permutation test. For the best model in each case, we report the annual percent change as well as the average annual percent change for the entire period under analysis. The average annual percentage change is defined as the weighted average of the annual percentage changes, with weights equal to the number of years in each time segment. Summary results are presented in Table 1 and Table 2. This study was reviewed by the Harvard TH Chan School of Public Health institutional review board and did not require full review because it uses publicly available, retrospective, de-identified data. From to , the opioid mortality rate for whites increased from 0. Over the same period, the rate for blacks increased from 0. While the rate for whites increased steadily over the whole period, the rate for blacks remained stable in — Table 1 and Figure 1. This differential growth is reflected in changes in the rate ratio white to black mortality through three successive waves. The rate ratio was approximately 0. A, Age-standardized opioid mortality rate for the white red and black blue US resident populations, — Dots are estimated rate. Solid lines are joinpoint model fits. We examined trends in mortality by broad opioid category heroin, methadone, and other to identify the drivers of change in the rate ratio. Both blacks and whites experienced an increase in heroin and other opioid mortality over the full period Table 1 and Figure 2. In , the heroin mortality rate was 0. By , the heroin mortality rates had risen to 4. The general pattern of increase in heroin mortality was similar for both populations: the rates first grew relatively slowly up to the s, reaching a plateau in for blacks and for whites, before accelerating after for whites and for blacks. Age-standardized opioid mortality rates by general type of opioid: heroin green , methadone orange , or other opioid violet for white top and black bottom US resident populations, — The mortality rate from other opioids increased from approximately 0. In contrast to heroin mortality, the trends in other opioid mortality over the period differ markedly by race. For whites, the rate increased substantially in —, while for blacks, it remained stable during this period. Opioid types can be further disaggregated during the period —, due to the ICD coding details Table 2 and Figure 3. Opioid mortality rates for International Classification of Diseases ICD years — by type for white top and black bottom US resident populations. By , the natural opioid mortality rate for whites was more than double that for blacks, at 4. The differential increase in natural opioid mortality by race explains the increase in the rate ratio from to The synthetic opioid mortality rate was 0. The opioid epidemic can be divided into three waves between and During the first wave, from to the mids, opioid mortality was higher for the black population, but rates of increase were similar for both populations and largely driven by heroin. During the second wave, from the mids to , the opioid epidemic expanded quickly within the white population while opioid mortality remained stable in the black population. As a consequence, the racial gradient of risk reversed in , and by , the opioid mortality rate were over 2 times higher for whites than for blacks. During this period, the opioid epidemic was driven largely by non-heroin and non-methadone opioids i. Lastly, from about to , the opioid mortality rate grew rapidly for both the black and white populations. This third wave has similarities to the first wave, as the mortality increase has been driven by heroin, and more recently synthetic opioids, in both populations. As reported in previous literature, 4 the acceleration in the mortality increase for whites since has been closely tied to an increase in the number of prescription drugs and the use of opioid pain medication, prompting several initiatives to curb the improper use of these painkillers. For example, in , OxyContin was reformulated to be less easily abused. In addition, there have been other government-led initiatives such as Prescription Drug Monitoring Programs, Medicaid Lock-in programs and pain clinic laws, which sought to limit access and deter overuse of prescription opioids. The focus on restricting the supply of prescription opioids without concurrently reducing demand, however, appears to be associated with a shift from prescription painkillers to heroin and other illicit opioids. In recent years, the supply of both heroin and illegally manufactured fentanyl has increased in the United States. Previous research has demonstrated a clear pathway of addiction from prescription opioids to heroin. However, the substitution of heroin for prescription opioids does not explain the recent rapid increase in the heroin and synthetic opioid mortality rates seen in the black population. Indeed, our findings show that the opioid mortality rate for blacks more than doubled in 5 years, even without a history of high prescription opioid mortality. Increased heroin mortality in more recent years is likely to be partly a consequence of the increased availability and affordability of heroin since In addition to physician training and restrictions to the supply of prescription opioids, recent policies to curb the opioid epidemic have included comprehensive efforts such as harm reduction and early addiction treatment. Our work contributes to the existing literature on understanding the opioid epidemic in three main ways. First, we presented an analysis of opioid mortality over an extended time frame, analyzing an additional 20 years of data prior to , when published studies usually begin. This longer time series highlights similarities between historical conditions and the most recent wave of the epidemic. Second, we focused our analysis on differences in opioid mortality by race, whereas previous research tends to focus on trends in the total population, or in the white population only, thereby omitting some key racial differences in the epidemic over time. Finally, examining trends by type of opioid provides evidence of shifts in the epidemic from heroin to prescription drugs to heroin and fentanyl. The current opioid epidemic in the United States is unprecedented compared to previous drug crises, in terms of the number of people affected and the rate of increase in overdose deaths. In particular, since , increases in mortality have been similar in both populations. The different patterns in the opioid epidemic by race suggest the need for targeted policy interventions to account for the distinctive pathways to addiction. A better understanding of racial differences and how they relate to the use of other drugs, place of residence, and socioeconomic status is necessary to improve health interventions and rehabilitation programs across the country. This study has several limitations. First, differences in cause of death reporting between blacks and whites could affect estimates of the rate ratio. The misclassification of race on death certificates could also affect the calculation of opioid mortality. However, although no validation studies have been carried out to examine the accuracy of coding of opioid deaths by race, an analysis of all causes of death showed that the effect on mortality of the misclassification of race on death certificates is small. Second, the jump joinpoint model assumes that the underlying trend remains the same during the ICD-9 to ICD transition. While there are no validation studies on the effect of the ICD change on opioid deaths specifically, the comparability ratio of accidental injuries under which accidental overdose—the overwhelming case of overdoses—is categorized is estimated to be 1. Indeed, the observed increase in fentanyl deaths since is likely attributable, at least in part, to improved detection through post-mortem investigations due to increased awareness in the medical community. Over the period to , age-standardized opioid mortality rates increased for both the white and the black populations. Although rates of increase were initially similar in the two populations and driven by heroin, the period — saw a rapid increase in opioid mortality for whites, largely due to prescription painkillers. Since , opioid mortality has been increasing rapidly in both groups, largely driven by increases in heroin and synthetic opioids. However, any opinions, findings, and conclusions or recommendations expressed in this material are those of the authors alone and do not necessarily represent the official views of the National Institute on Aging and other funders. As a library, NLM provides access to scientific literature. Find articles by Monica J Alexander. Find articles by Mathew V Kiang. Find articles by Magali Barbieri. Published by Wolters Kluwer Health, Inc. This article has been corrected. See Epidemiology. Open in a new tab. A and M. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.

Trends in Black and White Opioid Mortality in the United States, 1979–2015

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