For years, the nation’s long-running opioid crisis was primarily concentrated in rural, white communities. But as the epidemic evolved from one driven by prescription painkillers to one driven by deadlier and contaminated illegal drugs, overdose deaths surged among Black Americans and now surpass those of white Americans.
Much of the shift in the racial patterns of opioid overdose deaths can be explained by how changes in the drug supply interact with where people live, according to new research from experts at the RAND-USC Schaeffer Opioid Policy Tools and Information Center (OPTIC).
“The opioid epidemic today is fundamentally different than how it started 25 years ago or how it was 10 years ago. Understanding why that is the case and the various drivers of these shifts, as well as who is most impacted by them, is important for effective interventions today,” said co-author Rosalie Liccardo Pacula, co-director of OPTIC and a senior scholar at the USC Schaeffer Center for Health Policy & Economics.
The research, published in a new Health Affairs issue focused on the opioid crisis, examines county-level opioid overdose death rates from 1999 to 2020, spanning multiple, distinct waves of the epidemic. Before the proliferation of illicit fentanyl in 2013, researchers found where someone lived had little impact on racial and ethnic differences in opioid overdose deaths.
Since 2010, the opioid overdose rate among Black people increased by 8.4 overdoses per 100,000 more than among white people, which some erroneously contributed to a preference among Black people for illicit drugs rather than a geographic availability of a more lethal opioid. Researchers found about 40% of this widening gap can be attributed to how fentanyl first hit and initially spread in Eastern metropolitan areas, where about 57% of Black Americans live compared to 42% of white Americans. The geographic factor is about half as strong for opioid overdoses that also involve cocaine, as the shift to a polysubstance use crisis toward the end of the decade coincided with fentanyl spreading to more parts of the country.
The findings suggest that concerted place-based efforts can help narrow overdose disparities in hard-hit areas today. Programs like the Communities That Heal initiative bring together healthcare providers, recovery services, law enforcement and other stakeholders in a coordinated response.
At the same time, the study underscores that factors beyond geography—like treatment access and broader social and economic disparities—are also reshaping who is affected by the opioid crisis.
Accelerating opioid research
In a second Health Affairs article, Pacula proposes a uniform framework to help researchers studying the opioid crisis better approach and present opioid studies so that researchers can get solutions to policymakers faster.
There’s a large body of research using data from real-world settings to judge the effectiveness of different opioid policies, but contradictory findings have often created confusion among researchers, policymakers and the public. Part of the challenge is that researchers from a range of disciplines studying the crisis have their own methods to evaluate opioid policies and their own languages to communicate their findings, writes Pacula, who is also the Elizabeth Garrett Chair in Health Policy, Economics & Law at the USC Price School of Public Policy.
Pacula suggests that researchers increase transparency around study design and data limitations, pay greater attention to how their work differs from other studies when drawing comparisons, and better account for the changing landscape of opioid policies.
“Sound evaluation of opioid policies is an essential component of addressing the opioid crisis,” Pacula writes. “Greater clarity about the design, data, and methods in studies being conducted can improve communication between scientists thereby quickening the pace of science and better inform opioid policy.”
