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Opioid-Related Deaths in Massachusetts Remain Elevated Four Years after Peak

By Peter Ciurczak

September 17, 2021

As the COVID-19 pandemic continues to fill headlines, the opioid epidemic grinds on with few signs of improvement. In this research brief we analyze recent data on opioid-related deaths in Massachusetts, including data from the COVID time period, to help us keep sight of a crisis that continues wreaking havoc on lives to this day.

At the peak of the opioid epidemic in 2016, Massachusetts reached 29.7 deaths per 100,000 residents, more than two times the national rate (for further detail on the causes of this increase, please see our 2018 report Opioid Addiction Is a National Crisis. And It’s Twice as Bad in Massachusetts). While this rate has stopped climbing quite so dramatically, as of 2016 it has held steady at historically high rates, remaining in the high 20s per 100,000 and spiking back up to 30 per 100,000 during the peak of the COVID pandemic in 2020.

Fortunately, there are signs that opioid-related overdose deaths may yet decrease in 2021. During a Public Health Council meeting in August, MassDPH presented preliminary data showing that the first six months of 2021 saw an estimated 5 percent decrease in total deaths from the same period in 2020, which would roughly bring Massachusetts back to 2019 levels.

Since per capita rates are calculated against the total age-adjusted populationi, population growth can mask a rise in total deaths. Indeed, 2018 saw more opioid-related overdose deaths in Massachusetts than in 2016 even as this death rate was a touch lower. With the preliminary data that’s available for 2020, it appears that total deaths in 2020 reached another record high.

Also troubling is that while opioid-related overdose death rates for whites are down slightly, this has been offset by steady increases in Black and Latinx death rates over the past four years. Earlier in the epidemic, white residents were disproportionately dying of opioids. But in 2015, Latinx death rates sharply increased and began approaching white death rates. After a huge spike in Black opioid-related deaths during the COVID-19 pandemic in 2020, Black and Latinx opioid-related death rates exceeded white opioid death rates for the first time, and now all are roughly in the low 30s per 100,000. Interestingly, death rates for Asian Americans and Pacific Islanders (AAPI) are much lower. Other than for AAPIs, opioid-related overdose death rates for every racial group in Massachusetts are now more than twice the national average.

Though it is difficult to pinpoint any single cause of these increases, the pandemic likely exacerbated challenges for many residents, prompting them to turn to opioids as an adverse means of coping. When the state shut down to control the spread of COVID-19, Black and Latinx workers were often the first to be let go—provided they weren’t essential workers who continued working through the early months of the pandemic, often under trying circumstances. Black and Latinx workers saw unemployment rates of 12 and 15 percent, respectively, higher than white unemployment (at 9 percent) across the whole of 2020.

As these workers lost their jobs, it often became harder to feed their families and themselves. Around a quarter of adults in these groups reported low or very low food security across 2020, while around half of each group reported trouble paying for usual household expenses through the fall.

The virus itself also hit Black and Latinx communities especially hard, with both racial groups experiencing significantly higher infection and death rates. When adjusted for age, Black and Latinx COVID death rates were more than three times as high as rates for white patients as of August 2020 (the last point at which we were able to perform this comparison), and Black and Latinx residents continue to be hospitalized for COVID at higher rates than white residents.

For Black residents, the ongoing reckoning—or lack thereof—with America’s racist past and present may also be a contributor to opioid-related overdose deaths. Summer 2020 brought new evidence of the unfair and cruel ways the U.S. treats its Black residents and of the languishing nature of its promises to address these systemic problems.

Latinx residents have also seen pandemic impacts unique to them, compounding an already troubling rise in opioid-related deaths before the arrival of the coronavirus. In 2020, Latinx opioid-related death rates grew to 35.4 per 100,000, the highest among all populations in the state. Yet, the greatest increase in opioid-related deaths rates for the Latinx population occurred across 2015 and 2016, when death rates nearly doubled from 16 to 29 per 100,000. This overall increase mirrors national trends. In an attempt to understand this rise, the Substance Abuse and Mental Health Services Administration in 2020 published “The Opioid Crisis and the Hispanic/Latino Population.” The report found that, among other difficulties, many Latinx opioid users living in the U.S. may be coping with significant trauma and anxiety caused by fleeing difficult situations in home countries and/or the stressors of dealing with the American immigration system. The report further suggests that fear of the state, particularly the fear of deportation, looms large over many members of these groups, resulting in fewer calls to first responders in the event of an overdose. Finally, language and social barriers to treatment, such as a lack of knowledge of programs and/or stigma associated with opioid use, may also result in fewer “off-ramps” for users and consequently higher opioid-related death rates.

Just as the overall opioid overdose death rate masks racial and ethnic differences, the racial and ethnic death rates mask large differences by sex. Black and Latinx men in Massachusetts overdose on opioids at rates 3 and 4 times greater than Black and Latinx women, while white men overdose at 2.5 times the rate of white women. Moreover, Latinx opioid overdose rates among men in Massachusetts were the second highest in the nation in 2019, among states that reported data for Latinx residents (only Connecticut had a higher rate). Unfortunately, nearly all groups overdose at higher rates in Massachusetts than in the U.S. overall (with the likely exception of Asian American and Pacific Islander women).

One reason opioid-related overdose deaths have gone up across all demographics is the increasing prevalence of fentanyl. Within the last two decades fentanyl—a synthetic opioid 50 times stronger than heroin, originally made for hospital anesthesia or cancer pain relief—worked its way into in the illegal drug trade, and is now frequently combined with heroin, or more recently cocaine, to make these drugs more potent. Oftentimes users do not know their drugs have been laced with fentanyl, making overdose and death more likely. The impact that fentanyl has had on deaths can be seen in the chart below, which counts every drug found in the system of someone who has died due to an overdose. (Consequently, someone who died with both heroin and fentanyl in their system would be counted twice, once toward the heroin total, and once toward the fentanyl total.) Indeed, for the 1,969 opioid-related deaths in the Commonwealth reported to the Centers for Disease Control and Prevention in 2019, roughly 95 percent of them (1,861) included some amount of fentanyl. Massachusetts has also seen a rise in cocaine-related deaths, beginning in about 2012—and the story is similar here. Though a different class of drug than opioids, cocaine (a stimulant), like heroin, is increasingly laced with fentanyl. Stimulant users without a tolerance for opioids are at a higher risk of dying of an overdose, so it is perhaps unsurprising that in 2019, roughly 85 percent of cocaine-related deaths included fentanyl as well.

Overdose deaths due to fentanyl are much more common in New England states, as shown in the map below, than any other region in the country. This is in part due to access,ii,iii  as New Englanders live in a region well serviced by established drug-trafficking routes.iv  Market preferences may also have shifted; fentanyl has supplanted the heroin market in the region as of 2019.v

Though fentanyl-related opioid deaths continue to increase, there has been some success in reducing at least one contributor to the opioid epidemic—prescription opioid use. Prescriptions for opioid painkillers like OxyContin and codeine in Massachusetts fell from 47.1 per 100,000 in 2016 to 35.4 per 100,000 in 2019. Among the reasons for these drops were rising physician awareness of opioid abuse, regulatory changes, and ultimately lawsuits that have changed the behavior of the largest producers and distributors of prescription opioids. Unfortunately, illicit fentanyl producers and distributors are not so readily dissuaded. Reducing deaths from these substances will therefore require ongoing efforts to limit access to these drugs, and to provide the services necessary for users to escape their grip.

i From the CDC: “Age-adjusting [opioid-related overdose death] rates ensures that differences in incidence or deaths from one year to another, or between one geographic area and another, are not due to differences in the age distribution of the populations being compared.”

ii Special Maps Release: Tracking Fentanyl and Fentanyl-Related Compounds Reported in NFLIS-Drug, by State: 2018-2019, pg. 8.

iii The National Forensic Laboratory Information System (NFLIS) catalogues all drug analyses performed by federal, state and local authorities and laboratories on drugs in their custody. While assuredly not perfect, reports provided to the NFLIS are useful indicators of how much of any given substance is within a state. The higher the reports of a particular substance, the more of it is likely to be available more generally. These data show Massachusetts and New Hampshire both have fentanyl reports greater than 100 per 100,000, two of just a handful of states with reports that high. Notably, all New England states but Vermont have fentanyl reports that exceed heroin reports.

iv 2020 National Drug Threat Assessment, pg. 65.

v 2020 National Drug Threat Assessment, pg. 9.

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