Since the Centers for Disease Control and Prevention (CDC) first declared opioid use an “epidemic” in 2011, the threat has transformed from a crisis driven by prescription painkillers to one in which overdose deaths are predominantly caused by illicitly trafficked fentanyl, methamphetamine, and cocaine. Despite numerous public health initiatives to reduce overprescribing, overdose deaths from prescription opioids have continued at a tragically steady pace over the past several years.

A new issue brief from the University of Minnesota School of Public Health (SPH) State Health Access Data Assistance Center (SHADAC) helps fill in gaps in our understanding of the crisis. The analysis includes data on opioid use through 2021 — the most recent year for which there is national data available on opioid overdose death rates — in order to get a picture of opioid use 10 years after the CDC declared it a pandemic. By looking at data from 2020 and 2021, the SPH analysis is the most detailed study to evaluate how the opioid crisis evolved across the states during the pandemic. 

Key findings of SHADAC’s analysis include:

Fatal overdose deaths surged during the COVID-19 pandemic:

• During the first two years of the pandemic in 2020 and 2021, fatal drug overdose deaths surged, driven primarily by fentanyl, methamphetamine, and cocaine. In 2021, for example, the methamphetamine overdose death rate was double the 2019 rate.
• While fentanyl is the dominant cause of fatal overdoses in the U.S., overdose deaths involving the non-opioid drugs methamphetamine and cocaine have grown significantly during the past several years.

Overdose death rates vary by demographic groups

• Across drug categories, overdose death rates are highest among adults aged 25-54.
• Fentanyl overdose deaths were highest among American Indian and Alaska Native people, Black people, and white people; methamphetamine deaths were highest among American Indian and Alaska Native people and white people; and cocaine overdose deaths were highest among Black people.
• Drug overdose deaths increased significantly for all drug types across rural, small-to-medium metro areas, and large metro areas of the U.S.

Growing overdose deaths across the states

• The vast majority of states saw statistically significant increases in rates of fentanyl and methamphetamine overdose deaths (43 and 44 states, respectively). A majority of states also experienced statistically significant increases in cocaine overdose deaths (37 states).
• Rates of fatal overdoses from prescription opioids climbed significantly in 21 states — a sign of backsliding after recent years of steady or declining rates.

Deadly trends in Minnesota

• Although Minnesota’s fatal overdose death rates for fentanyl, prescription opioids, methamphetamine and cocaine were significantly lower than the U.S. average in 2021, they worsened significantly during the pandemic years of 2020 and 2021.
• Minnesota’s methamphetamine overdose death rate doubled during those years, and its fentanyl and cocaine overdose death rates almost tripled.

“While the pandemic surely played a role in America’s worsening opioid crisis, the reality is we were probably already primed for this catastrophe before anyone had ever heard of COVID-19,” said Colin Planalp, senior research fellow at SHADAC and lead author of the study. “The devastation we see in these data on overdose deaths are the grim result of decades of inadequate, ineffective, and often counterproductive drug policies. If the U.S. wants to reverse our decades-long trend of growing drug overdose deaths, we need to act with urgency and replace the strategies that have failed us.”

“The opioid crisis today is vastly more complicated than it was just 10 years ago,” said Andrea Stewart, research fellow at SHADAC and study co-author. “Not only have synthetic opioids like fentanyl eclipsed the prescription painkillers that triggered the crisis, but now non-opioids like methamphetamine and cocaine are also deeply intertwined. The longer we allow this situation to go on, the more complex it becomes and the harder it will be to solve.”