Drug Overdose Mortality Rates by Educational Attainment and Sex for Adults Aged 25 to 64 in the United States Before and During the COVID-19 Pandemic, 2015 to 2021 (preprint)

ABSTRACT

Introduction: Dramatic increases in U.S. drug overdose deaths involving synthetic opioids, most prominently fentanyl, beginning around 2014 have driven a marked progression in national rates of overall drug overdose deaths, which sharply rose to unprecedented levels amid the COVID-19 pandemic. Disparities in U.S. drug overdose mortality burden by educational attainment have not been widely scrutinized during the fentanyl era of the drug overdose epidemic and its intersection with the COVID-19 pandemic. Methods: Utilizing restricted-use mortality data from the National Vital Statistics System and population estimates from the American Community Survey, we estimated annual national age-adjusted drug overdose mortality rates jointly stratified by educational attainment and sex for adults aged 25-64 from 2015 to 2021. State-level age-adjusted mortality rates were estimated in 2015 and 2021 to examine geographic trends in the cumulative evolution of disparities in drug overdose deaths by educational attainment over the course of the analysis period. Results: Over 452,700 drug overdose deaths among U.S. adults aged 25-64 occurred from 2015 to 2021. For both men and women in this age range, age-adjusted mortality rates rose fastest among persons with at most a high school-level education, whereas little to no change in age-adjusted mortality rates was observed for Bachelors degree holders, widening pre-existing disparities in drug overdose mortality burden by educational attainment. During the analysis period, the difference in age-adjusted mortality rates between persons with at most a high school-level education and Bachelors degree holders, for both men and women, increased from less than 8-fold to approximately 13-fold. These disparities widened in nearly every state, and the widening accelerated after the onset of the COVID-19 pandemic. Among non-Bachelors degree holders, age-adjusted mortality rates increased markedly faster among men. Conclusions: The widening disparities in drug overdose deaths by educational attainment are a likely indicator of a rapidly-increasing socioeconomic divide in drug overdose mortality more broadly. Policy strategies should address the upstream socioeconomic drivers of drug use and overdose, especially among men, and tailor interventions accordingly.