Photo of Pills

Opioid Overdose Epidemic Hits Hardest for The Least Educated

The prescription opioid painkillers that helped fuel the surge in U.S. drug overdose deaths were first approved by the Federal Drug Administration in late 1995.

The before-and-after fatality rates tell a shocking story: In 1994, the age-adjusted drug overdose death rate was 4.8 deaths per 100,000 people; by 2015, the rate had more than tripled to 16.3 per 100,000.1 Since then, the overdose death rate has continued to climb. Provisional estimates for 2016 suggest it reached 19.8 deaths per 100,000, more than quadrupling since 1994.2 While prescription opioids fueled the initial surge in overdose deaths after 1995, heroin and fentanyl-type compounds—which tend to be illicitly produced—are the main drivers now.

“Intense attention and action” is what experts at the U.S. Centers for Disease Control and Prevention (CDC) argue is needed to counter the epidemic.

Key to any response is an understanding of the people and places hardest hit, says Jessica Ho of the University of Southern California.

Shannon Monnat of Syracuse University agrees. “Overdose deaths are not randomly distributed across the country.”

These researchers point out that the steep rise in fatal overdoses is unusual and unanticipated, occurring at the same time that death rates from heart disease, cancer, and injury-related causes have declined.

The only other comparable surges in deaths in high-income countries are alcohol-related deaths in the former Soviet Union and the HIV/AIDS epidemic in Europe and North America, Ho reports.

A Higher Toll Among the Least Educated

The U.S. opioid epidemic has taken the lives of rising numbers of people with all levels of education. However, deaths have grown increasingly more concentrated among those with lower levels of education, particularly among non-Hispanic whites (see figure).


animation showing rate of opoid addiction


More-educated adults in the United States tend to live longer than less-educated individuals. The differences increase in a stair-step pattern by education level, with the widest difference between college graduates and those without high school degrees. This gap has widened over the past two decades, resulting in part from steep increases in drug overdose deaths among those without college degrees, reports Ho in an article published in the journal Demography.3

Ho analyzed life expectancy differences by education level, using data for 1992 through 2011 from the National Health Interview Survey combined with data from the National Vital Statistics System. She focused on adults ages 30 to 60—the prime working years—because this age group is disproportionately affected by the overdose epidemic.

Her analysis shows that between 1992 and 2011 drug overdose deaths represented a sizable share of the widening difference in life expectancy among college graduates and those with less education. For example, among non-Hispanic whites, opioid deaths account for 99 percent of the growth in the life expectancy gap between men with college degrees and those without high school diplomas; among women, opioid deaths could be blamed for 42 percent of the growth in the life expectancy gap between the two education groups.

Ho argues that people with low education levels often experience limited job opportunities and poor economic prospects, leaving them vulnerable to depression, despair, and drug addiction. Among the Interrelated reasons for this:

  • Less-educated individuals tend to work in settings that “increase their risk of workplace injuries, disability, and chronic health conditions, which lead to a greater likelihood of being prescribed opioid painkillers,” raising their risk of addiction.
  • People with low education levels are more concentrated in rural areas, where the emergency medical response for overdose victims may be more limited.
  • Less-educated individuals who also have limited incomes may have greater financial incentives to participate in schemes that involve reselling opioids (such as seeking prescriptions from multiple doctors), which also increase their access to these drugs and the likelihood of addiction.
  • Compared with more-educated people, less-educated people “may have fewer resources to combat drug addiction, including financial resources, access to scarce slots in drug treatment programs, and support from social networks.”

Strategies to address the opioid crisis should consider the economic constraints and treatment barriers that people with low education levels may face, she argues.

Women’s Overdose Rates Rising Closer to Men’s

Historically, men have had higher drug overdose rates than women, but the difference is narrowing slightly with the current epidemic. In the Demography study described above, Ho sees a “gender convergence,” with women’s overdose death rates increasing more rapidly than men’s and rising closer to their levels (see figure above).

Her analysis of overdose death rates over time shows that men without college degrees would have been better off in 2011 if their drug overdose rates dropped to the 2011 levels observed for college-educated men, rather than if their rates returned to pre-epidemic levels for men without college degrees. These results suggest that mortality differences by education remain “fairly sharp” for men. But for women, Ho shows that high school graduates and those with some college would have been better off in 2011 if their overdose rates dropped back to the level their own education group had in the early 1990s, indicating that these two groups of women experienced large increases in overdose deaths.

One reason women’s overdose rates have risen so rapidly recently may be that women tend to be more connected to the health care system and visit health care providers more often than men. They thus may be prescribed prescription painkillers at higher rates, Ho suggests. Evidence shows that compared with men, women may become addicted more quickly and have greater difficulty quitting, she reports.

Opioid Death Rates Increasing Among Blacks

In analysis that focuses exclusively on opioid-related drug fatalities, researchers’ preliminary findings show that between 2010 and 2015 mortality rates increased faster for blacks than whites.4 Monica Alexander and Magali Barbieri of the University of California, Berkeley; and Mathew Kiang of Harvard University examine vital statistics data on opioid-related deaths by race between 2000 and 2015, demonstrating that the opioid epidemic is not “white only.”

For 2015, they calculate that the opioid-related overdose mortality rate for whites was 12.2 per 100,000, nearly twice the rate for blacks (about 6.6 per 100,000). However, between 2000 and 2015, the opioid death rate increased 51 percent among whites but 87 percent among blacks.

To understand these dynamics, Alexander, Barbieri, and Kiang examine two different time periods and different types of opioids. Between 2000 and 2010, whites experienced much larger increases in opioid overdose deaths than blacks, mainly due to a rise in fatalities from prescription opioid painkillers. But between 2010 and 2015, both blacks and whites experienced sizeable increases in their opioid overdose death rate. This increase is mainly related to a rise in deaths from illicit opioids—heroin and highly potent fentanyl-type compounds.

In addition, the researchers find that deaths related to heroin and fentanyl-type drugs increase with age among blacks, but are more concentrated among younger whites.


The U.S. opioid epidemic has taken the lives of rising numbers of people with all levels of education.


They note that after 2010 the prescription painkiller OxyContin was reformulated to be less addictive, and distribution restrictions at the national and state levels began. These changes may have contributed to a greater demand for heroin, leading to a growing supply and falling prices. More lethal types of heroin laced with fentanyl also became more widely available after 2010.

Because increases in overdose death rates show no sign of slowing, Alexander, Barbieri, and Kiang argue that policymakers aiming to improve health policy and rehabilitation programs should consider how different racial groups tend to abuse different drug types.

Economic Distress, Job Loss Key

Drug overdose deaths are not evenly spread across the country, as ongoing research that also examines deaths from suicide and alcohol shows. Just as people with specific characteristics face higher risks, certain places are “shouldering a much heavier burden” than others, reports Shannon Monnat.5

She shows that rural (nonmetropolitan) and small urban counties that have high concentrations of deaths from drug overdose, suicide, and alcohol abuse also tend to feature:

  • Large shares of economically vulnerable residents—based on a composite index that includes poverty, unemployment, disability, households headed by single parents, lack of health insurance, and public assistance receipt.
  • Declines in median household income since 1980 stemming from job losses in manufacturing and natural resources.

In Monnat’s view, interventions should target communities with populations in “significant economic distress,” focusing on “places that have experienced major labor market shifts and income decline over the past four decades.”

Specifically, policymakers should consider initiatives such as “employment and training opportunities for those without a college degree, particularly in places most affected by blue-collar manufacturing and natural resource job loss.”

“Ultimately, this is not a uniformly national crisis, and we are unlikely to ‘Narcan’ [brand name of overdose reversal drug] our way out,” she argues. “Failure to consider the underlying economic causes could lead to ineffective policy strategies.”

This article was produced under a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). Research conducted at the following NICHD-funded population research centers was highlighted in this article: University of California at Berkeley, Duke University, and Penn State University.



[1]  Centers for Disease Control and Prevention (CDC), National Center for Health Statistics, “Compressed Mortality File 1999-2015,” CDC WONDER Online Database, accessed at, on Dec. 13, 2017; and Holly Hedegaard, Margaret Warner, and Arialdi Miniño, “Drug Overdose Deaths in the United States, 1999–2015,” NCHS Data Brief, no 273 (Hyattsville, Md.: National Center for Health Statistics, 2017).

[2]  F.B. Ahmad and B. Bastian, “Quarterly Provisional Estimates for Selected Indicators of Mortality, 2016–Quarter 2, 2017,” CDC, National Center for Health Statistics, National Vital Statistics System, Vital Statistics Rapid Release Program, 2017, accessed at, on Jan. 2, 2018; Note: Choose overdose death rates from the drop-down menu in the first column.

[3]  Jessica Y. Ho, “The Contribution of Drug Overdose to Educational Gradients in Life Expectancy in the United States, 1992-2011,” Demography 54, no. 3 (2017): 1175-1202.

[4]  Monica Alexander, Magali Barbieri, and Mathew Kiang, “Opioid Deaths by Race in the United States, 2000-2015,” paper presented at the annual meetings of the Population Association of America, Chicago, April 27-29, 2017, accessed at, on Nov. 29, 2017, DOI: 10.17605/OSF.IO/75KR2.

[5]  Shannon Monnat and David L. Brown, “More Than a Rural Revolt: Landscapes of Despair and the 2016 Presidential Election,” Journal of Rural Studies 55, no. 1 (2017): 227-37; Shannon Monnat, “Drugs, Alcohol, and Suicide Represent Growing Share of U.S. Mortality,” Carsey Research, University of New Hampshire, Carsey School of Public Policy, National Issue Brief No. 112 (Winter 2017); and Shannon Monnat, “Deaths of Despair from the Cities to the Hollers: Explaining Spatial Differences in U.S. Drug, Alcohol, and Suicide Mortality Rates,” paper presented at the annual meetings of the Population Association of America, Chicago, April 27-29, 2017.