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Too Many Lives Lost: Comparing Overdose Mortality Rates and Policy Solutions Across High-Income Countries

Six-year-old Joshua Gallegos and his mother Aretta Gallegos sit outside their home in Northglenn, Colo., on Apr. 28, 2022. Aretta’s daughter, Brianna Mullins, was one of 105,000 overdose deaths in the United States in 2021. Photo: R.J. Sangosti/MediaNews Group/Denver Post via Getty Images

Six-year-old Joshua Gallegos and his mother Aretta Gallegos sit outside their home in Northglenn, Colo., on Apr. 28, 2022. Aretta’s daughter, Brianna Mullins, was one of 105,000 overdose deaths in the United States in 2021. Photo: R.J. Sangosti/MediaNews Group/Denver Post via Getty Images

Authors
  • Jesse Baumgartner
    Jesse C. Baumgartner

    Research Associate, Health Care Coverage and Access & Tracking Health System Performance, The Commonwealth Fund

  • Evan Gumas headshot
    Evan Gumas

    Research Associate, International Health Policy and Practice Innovations, The Commonwealth Fund

  • Munira Z. Gunja
    Munira Z. Gunja

    Senior Researcher, International Program in Health Policy and Practice Innovations, The Commonwealth Fund

Authors
  • Jesse Baumgartner
    Jesse C. Baumgartner

    Research Associate, Health Care Coverage and Access & Tracking Health System Performance, The Commonwealth Fund

  • Evan Gumas headshot
    Evan Gumas

    Research Associate, International Health Policy and Practice Innovations, The Commonwealth Fund

  • Munira Z. Gunja
    Munira Z. Gunja

    Senior Researcher, International Program in Health Policy and Practice Innovations, The Commonwealth Fund

Toplines
  • Drug overdose deaths in the U.S. have reached levels far above those in most other high-income countries; key policy differences may help explain why and provide strategies to address the problem

  • The spike in drug overdose deaths in 2021 may be the result of factors like social isolation, addiction treatment interruption, and stronger synthetic opioids like fentanyl

Drug overdose deaths in the United States spiked during the COVID-19 pandemic; recent estimates from the Centers for Disease Control and Prevention indicate that more than 105,000 lives were lost in 2021. This level of preventable mortality stands in stark contrast to international peer countries and is contributing to an unprecedented decline in U.S. life expectancy.

In this post we compare the U.S. to other high-income countries in drug overdose deaths and then highlight differences in behavioral health care, drug policies, and social services, and look at recent U.S. initiatives.

Understanding and leveraging international models can help the U.S. reduce overdose deaths and enact more compassionate, evidence-based policy around drug use.

Overdose/Drug-Related Deaths Are Highest in the United States, Followed Closely by Scotland

Data released during the past year showed a dramatic increase in U.S. drug overdose deaths after COVID-19 emerged, with nearly 92,000 lives lost in 2020. Provisional data indicate that more than 105,000 lives were lost in 2021. Researchers have pointed to factors such as social isolation, addiction treatment interruption, and stronger synthetic opioids like fentanyl.

These staggering numbers are well above most international peer countries. Analysis of the latest publicly available data from each country finds that in 2020, the U.S. had the highest unadjusted rate of drug overdose deaths — 277 lives lost per million residents. Based on provisional data, the rate was likely near 320 lives per million residents in 2021. Scotland, which has long reported higher overdose mortality than the rest of the United Kingdom, is next at 267 deaths per million residents, followed by Canada with an opioid-related death rate of 171 deaths per million residents. In contrast, all other countries in the exhibit are below 100 deaths per million residents.

Many other countries also reported upticks in overdose deaths during 2020. While Canada stood out with a 77 percent increase in opioid-related deaths, rates for Germany and Norway started from a much lower level and increased by a lower percentage than the United States did. (See the appendix for 2019–2020 changes and differences in mortality data between countries.)

chart: Overdose/drug-related deaths are highest in the United States, followed closely by Scotland.

International Approaches and Data Can Help Guide U.S. Reforms

There are clear policy differences between the U.S. and the many peer countries with fewer overdose deaths:

U.S. drug policy leans more heavily on law enforcement to the detriment of treatment

The United States criminalizes drug use and incarcerates people at a much higher rate than peer countries, with disproportionate impact on people of color. Enforcement has not led to fewer overdose deaths, and criminalization has contributed to stigma and hesitance for patients seeking treatment. Although many incarcerated people have a drug use disorder, they often cannot access treatment in the justice system.

Other countries have implemented policies which focus on helping, rather than punishing, people struggling with addiction. Portugal, a country with much lower overdose mortality, decriminalized the personal use of illicit drugs and instead uses local commissions that include health care professionals to assess an individual’s need for treatment. In England, which has an overdose mortality rate well below that of the U.S., the government previously instituted an arrest referral program that helps people access treatment.

The U.S. provides less access to drug treatment and harm-reduction services

Americans who could benefit from drug treatment usually do not receive it. Data show that in many peer countries, 50 percent or more of adults with high-risk opioid use are receiving medications like methadone that reduce the risk of overdose. In contrast, only 11 percent of Americans with opioid use disorder reported receiving these treatments in 2020.

chart: People with high-risk opioid use are much more likely to access effective addiction treatments like methadone internationally than in the United States.

In the U.S, strict federal regulatory guidelines limit which providers can prescribe and administer treatments and where they can do so. In comparison, countries like France and the U.K. have made it easier for primary care doctors to give their patients medications like methadone and buprenorphine.

For people actively using drugs, some countries have embraced strategies to maximize safety, like needle exchange programs, supervised drug-consumption sites, national programs that distribute naloxone (an opioid overdose reversal drug), and drug-checking services that provide people information on the composition of drugs (e.g., presence of fentanyl).

The U.S. has weaker mental health care

Nearly half of Americans living with a substance use disorder also report mental illness, but are often less able to access mental health care compared with international peers. These difficulties are compounded by limited U.S. mental health workforce capacity, one of the lower among high-income countries. Countries with better access and capacity, like the Netherlands, have taken approaches that prioritize mental health within primary care and use harm-reduction and drug-treatment programs as a foundation for connecting patients to mental and general health practitioners.

The U.S. invests less in social support services

Overdose death risk has been associated with socioeconomic factors such as employment, housing, income, disability, and education. Compared to its OECD peers with lower drug-related mortality, the U.S. spends less on social services — like childcare and employment assistance — that support younger, working-age populations. Expanding social spending could improve outcomes by addressing socioeconomic burdens associated with substance use disorder and mortality.

Looking Forward

U.S. overdose deaths have reached crisis levels. Lower mortality rates in other countries indicate we can learn from their experiences and strategies.

Encouragingly, recent domestic initiatives take aim at several of the gaps we identified. These include commitments by the Biden administration to expand the behavioral health workforce, improve addiction treatment access by relaxing federal restrictions around the use of telehealth and take-home medication, and invest in harm reduction.

States also are enacting promising reforms. Those include a transition from drug criminalization to treatment in Oregon, broader behavioral health integration and diversion programs in Arizona, treatment expansion within Rhode Island criminal justice facilities, and safe drug-consumption sites in New York City.

DATA AND METHODS

Exhibit 1 (overdose mortality) and Exhibit 2 (opioid substitution therapy coverage) use data from a wide range of U.S. and international sources. These data sources and metrics can have important differences in methodology, indicator definition, and population measured, and the findings are not necessarily comparable in all instances.

For example, the definition of drug overdose deaths reported in the United States does not match up directly with the definition of “drug-induced deaths” collected in some European countries by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Or in the case of Canada, only opioid-related mortality statistics for 2020 are included. Overdose mortality rates presented are also unadjusted for population age differences, though using the ages 15–64 population in each country as the denominator results in a nearly identical rank order (see the appendix).

However, the two exhibits represent the most comparable and available international data for these metrics and provide an important foundation for understanding current international differences in both areas. They also represent the need for further international data standardization and collaboration.

In the appendix, we have detailed and documented sources and definitions for each of the data points used in both exhibits, including potential limitations that should be considered when comparing countries.

ACKNOWLEDGMENTS

The authors are extremely grateful for dialogue, data guidance, and data provision from a range of international health researchers, including: Dr. Gordon Hay (Liverpool John Moores University); Dr. Ane-Kristine Finbråten (2021–22 Harkness/Norwegian Institute of Public Health Fellow, Ullevål Hospital Postdoctoral Fellow, Unger Vetlesen Institute); Chris Lewis (New Zealand Ministry of Health); Kali Mercier (NZ Drug Foundation); Jeong Eun Min and Dr. Bohdan Nosyk (Centre for Health Evaluation and Outcome Sciences [Min, Nosyk] and Simon Fraser University [Nosyk]); Dr. Filippo Pericoli, Dr. Alessandro Pirona, Thomas Seyler, Bruno Guarita, and Linda Montanari (EMCDDA); Dr. Rachel Sutherland, (University of New South Wales, Sydney); Dr. Mimmi Eriksson Tinghög (Public Health Agency of Sweden); and Cayley Russell (Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, CAMH, and Canadian Research Initiative in Substance Misuse, CRISM). They are also acknowledged in the appendix regarding specific data points.

Publication Details

Date

Contact

Jesse C. Baumgartner, Research Associate, Health Care Coverage and Access & Tracking Health System Performance, The Commonwealth Fund

[email protected]

Citation

Jesse C. Baumgartner, Evan Gumas, and Munira Z. Gunja, “Too Many Lives Lost: Comparing Overdose Mortality Rates and Policy Solutions Across High-Income Countries,” To the Point (blog), Commonwealth Fund, May 19, 2022. https://doi.org/10.26099/r689-fk36