Earlier this week, CDC released provisional figures for drug overdose deaths in the USA in 2019. They estimate almost 72,000 deaths, the highest annual number yet seen. Initially driven by prescription opioid painkillers, users migrated first to heroin and then to fentanyl, which is cheaper (much of it illicitly made). Synthetic opioids accounted for an estimated 36,500 deaths.

The WHO Global Health Estimates  included estimates of direct deaths due to drug use disorders, including accidental poisoning by drugs and overdose deaths, as well as deaths coded to drug dependence (see Technical Note for methods and data).   Last year I updated these to year 2017 using the latest death registration data from the WHO Mortality Database, as well as recent reports for selected countries, and estimates of drug deaths from the IHME GBD 2017. It was apparent at the time that the USA was a massive outlier globally, responsible for a disproportionate proportion of global overdose deaths. I’ve increasingly noticed that the USA is an outlier from other developed countries for a number of health and social indicators, most recently the coronavirus pandemic, police killings, gun homicides and incarceration rates. I was interested to see how the USA compared with other countries for drug-related deaths, given its enormous investment in and the human cost of the “war on drugs”. I’ve done a quick update as described below, but I am fairly sure it gives a reasonably good general picture, not too different from the earlier 2017 update for WHO or the IHME GBD 2017 estimates.

I estimate that globally, drug use disorders caused close to 181,000 deaths in 2019, of which 40% were in the USA. The global average death rate for drug use disorders was 15 per million population, compared with 219 per million for the USA. In other words, the USA rate is 15 times higher than the global average.

I have projected recent trends forward to 2019 and updated drug death estimates for the USA, Canada, Australia and China based on recent reports. The analysis of death registration data is complicated by the need to distribute the accidental poisoning category for “other and unspecified chemicals and noxious substances” (X49) to the specific categories for alcohol and drug use disorders (opioids, cocaine, amphetamines, cannabis and “other drugs”) and to accidental poisoning (non-drug and non-alcohol). Additionally, there is a category F19 in the mental health chapter for “multiple drug use and unspecified drug use disorders” which is used to code deaths in some countries and also must be redistributed appropriately. So there is some uncertainty associated with the estimates for countries with death registration data, and even more for countries without good data. The GHE includes cannabis use disorders as a category, but I have not shown it in the graphs here as there are no overdose deaths.

In terms of the overall drug disorder death rate in 2019, the four leading countries were the USA (219 per million), Canada (121), Australia (71) and Russia (63). Opioids are responsible for many more deaths than other types of drugs.  The following graph shows the drug use death rates for the 15 leading countries in 2019, with the contributions of opioids, cocaine, amphetamines and other drugs.

The following graph shows time trends for opioid death rates in selected countries from 2000 to 2019.

The USA and Canada stand out as having substantially increasing opioid overdose death rates over the last decade. In fact, the opioid death rate for the USA has been growing exponentially since the 1980s until 2017, when there was a 5% drop for 2018, followed by a rise to slightly higher than the 2017 peak in 2019.  Its still too early to say whether the US drug death rates are stabilizing or will start to fall. A recent paper by Jalal et al (Science 2018) shows that the US drug overdose death rate fits an exponential curve from 1980 to 2016 resulting from multiple subepidemics with changing patterns of overdose deaths by age distribution (see graph below).

Source: Jalal et al. Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016. Science. 2018 

The following regional graphs highlight how different the situation in North America is to the rest of the world.

In this post, I have focused on direct deaths associated with drug use. However, drug use also raises risks for road injury deaths and suicide, and injecting drug users also face increased risks of death from HIV, hepatitis B and hepatitis C. Together, direct and indirect deaths associated with drug use account for close to half a million deaths annually in the world, and the great majority of these (74%) are associated with opioid use [conference-presentations #131].