The Drug Overdose Epidemic Affects All Communities

In the last few decades, the drug overdose epidemic has worsened dramatically. The number of deaths from drug overdoses has skyrocketed, particularly among White people and people who live in rural areas. This aspect of the epidemic has gotten a lot of attention, because the rate has been increasing so quickly. However, it is not the whole story of the drug overdose epidemic.

A new NIH analysis of drug overdose deaths shows that the epidemic is huge and national, affecting people of all racial and ethnic groups, in cities, suburbs, small towns, and rural areas, and rates of drug overdose are rising among almost all groups.1 Most U.S. overdose deaths involve opioids, a group of drugs that includes illegal drugs like heroin and prescription pain medicines like oxycodone (OxyContin) and hydrocodone (Vicodin). In 2017, the U.S. Department of Health and Human Services declared the opioid crisis a national public health emergency. Recently, the Centers for Disease Control and Prevention (CDC) published a report on preliminary data showing a significant decline in prescription use-related deaths for the first time since 1990. However, deaths from other opioid use continue to rise.

Colorful image of people spread across a U.S. map layered over pills with buildings representing rural, urban and suburban settings across the bottom

“News of the declining death rate for prescription drug use is encouraging, yet we are greatly concerned about the rising number of deaths that continue for other segments of opioid and other drug users and recognize these drug overdoses cross racial, ethnic, geographic location and socioeconomic status lines,” said NIMHD Director Eliseo J. Pérez-Stable, M.D., one of the authors of the new study. “There is an urgent need for multifaceted approaches to reduce and even eliminate mortality due to fatal drug poisoning.”

Shape of an Epidemic

Opioids bind to receptors on nerve cells in your body. The drugs block pain but can also slow your breathing and digestion. In an opioid overdose, your breathing and heartbeat can slow to a dangerously low rate. An overdose of a stimulant like cocaine or methamphetamines, on the other hand, speeds your heart rate and raises your blood pressure to dangerous levels.

Drug overdoses were increasing very slowly through the 1980s but took off in the late 1990s as prescriptions for opioid pain medicines increased. A second wave of the epidemic began in 2010, when overdose deaths related to heroin started to increase among younger people, predominantly those ages 20 to 40.2 Meanwhile, several factors contributed to a reduction in overdose deaths related to opioid prescriptions; one study suggests that physicians were cutting back on opioid prescriptions because of worries about overdoses, and people who were already addicted to prescription opioids were switching to heroin.2

In 2013, a third wave of overdose deaths began, with a sharp increase in deaths involving fentanyl. Fentanyl is a prescription opioid, but it can also be synthesized illegally and is often added to heroin and cocaine. In 2017, more than two-thirds of drug overdose deaths in the United States involved an opioid, and more than half of those deaths involved fentanyl.1 Overdose deaths involving cocaine and other stimulants have also started increasing; according to the CDC report, the death toll involving this drug category rose significantly in 2018. Many people who died of overdoses were using multiple drugs; cocaine overdose deaths often also involved an opioid.3

A Closer Look

The new analysis focused on premature deaths—that is, deaths of people ages 25 to 64.1 The researchers combined the death certificate information that the CDC collects with U.S. Census data on the counties where people lived, including the median household income, how rural the county was, and what percentage of its population was unemployed.

Of the groups studied—African Americans, Latinos, and Whites—Whites generally had the highest overdose rates, and those rates also increased sharply: From 2000 to 2015, drug overdose death rates went up by more than 10% per year among White men and women. But rates also rose quickly in other groups: For example, overdoses went up almost 10% a year for African Americans aged 50 to 64. Young Latinas’ overdose rates also increased quickly.

Looking at where overdose deaths occurred, the researchers found that rural areas had the highest rates of drug overdose deaths. However, these still represented a relatively small number of overdoses nationwide. The researchers found that 75% of drug overdose deaths from 2012 to 2015 were in large metropolitan counties, while only 1% occurred in the most rural areas.4

“I was surprised to learn that drug overdose death rates are increasing in all types of communities—rich, poor, rural, and metropolitan,” said Meredith S. Shiels, Ph.D., a National Cancer Institute (NCI) investigator and lead study author. “The epidemic impacts people everywhere in the U.S., regardless of the socioeconomic situation of the counties where they live.”

The researchers did not consider which drugs were in a person’s system when they died. Other research has shown that African American men and women who overdosed were more often taking cocaine.3,5 However, many of those deaths may have actually been caused by opioids, since cocaine and opioids are often taken in combination. According to NIH-supported studies, these deaths indicate an important, long-term public health problem that is often overlooked.5 Strategies to combat the U.S. prescription opioid and heroin epidemics remain critical for all race and ethnic groups, but additional efforts focused on the prevention of cocaine-related deaths, which disproportionately affect African Americans, are needed.5

Drug overdose deaths from 2012 to 2015 were generally highest in counties with the most unemployment, lower levels of education, and a low median income. But this trend was not generally true for African Americans and Latinos. “These socioeconomic factors have a stronger impact on Whites,” says Erik J. Rodriquez, Ph.D., M.P.H., study co-author and staff scientist in the Minority Health and Health Disparities Population Laboratory at the National Heart, Lung, and Blood Institute. This was a surprise, he said: “It may be that socioeconomic changes are affecting Whites at a faster pace, which may affect their perception and make them think that things are worse despite data to show that the general socioeconomic conditions of African Americans and Latinos are objectively poorer than that of Whites.”

“If someone asks, ‘What is the cause of the opioid crisis?’ most people who work on opioids say it is a failure to take care of pain and a failure to care for mental health,” said Benyam Hailu, M.D., M.P.H., a medical officer for NIMHD. Prescription and illegal opioids soothe both mental and physical pain. Many people with opioid use disorder also have depression, bipolar disorder, or schizophrenia. The opioid crisis may be part of a larger, longer-term process. Economic, sociological, and psychological factors, such as despair, loss of purpose, and dissolution of communities, may be at work to accelerate the crisis.2

Dr. Hailu also noted that the new study was only able to look at Whites, African Americans, and Latinos, but American Indians and Alaska Natives have also been severely affected by the overdose epidemic. Overdose rates for American Indians and Alaska Natives have increased dramatically in recent years; opioid overdose rates are almost as high for American Indians and Alaska Natives as for Whites.1

What NIH Is Doing

NIH’s Helping to End Addiction Long-term℠ (HEAL) Initiative is taking on the national opioid public health crisis via two prongs: looking for better treatments for pain and improving treatments for addiction. NIMHD is working with 10 other NIH Institutes and Centers on research that will have components related to populations experiencing health disparities, such as African Americans, American Indians and Alaska Natives, and people who live in rural areas.

Separately from HEAL, NIMHD is also working with other Institutes and Centers to fund research related to health disparities and the opioid epidemic. The funding opportunity announcement (FOA) calls for research on opioid use in populations experiencing health disparities, including understanding how opioid prescribing relates to race and ethnicity and how to reduce gaps in treatment. The first project funded under this FOA received funding from the National Institute on Drug Abuse (NIDA) to study differences in access to treatment for opioid use disorder for men and women.

In addition, NIH is supporting projects addressing addiction and substance abuse in general across the United States. For example, within Collaborative Research on Addiction at NIH (CRAN), NIDA is focusing on advancing research on addiction and drug abuse. The CRAN plan involves determining risk factors and signs of addiction, as well as identifying the connections among substances of abuse. CRAN hopes to use this additional insight to help prevent the onset or increase of substance use, particularly in vulnerable populations.

There are multiple aspects to the issue of drug abuse, including genetic, environmental, social, and socioeconomic factors that contribute to this crisis. By funding research on the opioid crisis, NIMHD hopes to find out more about what is causing the drug overdose epidemic—and how to address it.


  1. Scholl, L., Seth, P., Kariisa, M., Wilson, N., & Baldwin, G. (2019). Drug and opioid-involved overdose deaths — United States, 2013–2017. MMWR Morbidity and Mortality Weekly Report, 67, 1419-1427. doi:10.15585/mmwr.mm675152e1
  2. Jalal, H., Buchanich, J. M., Roberts, M. S., Balmer, L. C., Zhang, K., & Burke, D. S. (2018). Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016. Science, 361. pii: eaau1184. doi:10.1126/science.aau1184
  3. Kariisa, M., Scholl, L., Wilson, N., Seth, P., & Hoots, B. (2019). Drug overdose deaths involving cocaine and psychostimulants with abuse potential — United States, 2003–2017. MMWR Morbidity and Mortality Weekly Report, 68, 388-395. doi:10.15585/mmwr.mm6817a3
  4. Shiels, M. S., Berrington de González, A., Best, A.F., Chen, Y., Chernyavskiy, P., Hartge, P. (2019). Premature mortality from all causes and drug poisonings in the USA according to socioeconomic status and rurality: an analysis of death certificate data by county from 2000–15. The Lancet Public Health, 4, PE97-PE106. doi: 10.1016/S2468-2667(18)30208-1
  5. Shiels, M. S., Freedman, N. D., Thomas, D., & Berrington de Gonzalez, A. (2017). Trends in U.S. drug overdose deaths in non-Hispanic Black, Hispanic, and non-Hispanic White persons, 2000–2015. Annals of Internal Medicine, 168, 453-455. doi:10.7326/M17-1812

Page updated Jan. 12, 2024