Drug policies and annual opioid overdose mortality in U.S. states with the five worst and five best trends between 2018 and 2023: an ecological study
- 1Institute for Global Health Sciences, University of California, San Francisco, CA, USA
- 2Family and Community Medicine, University of California, San Francisco, CA, USA
- 3Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
Abstract
Purpose: To examine state-level opioid overdose mortality trends in the United States and assess their association with drug policy environments.
Methods: This ecological study analyzed opioid-related overdose death data from 2018 to 2023 for all U.S. states using CDC WONDER. Linear regression estimated state-level mortality trends. The five states with the steepest increases and five with the most stable or improving trends were identified. Drug policies for these ten states were reviewed using the Global Drug Policy Index and correlated with mortality trends.
Results: Opioid overdose deaths totaled 405,682 nationally, with the crude death rate peaking at 29.8 per 100,000 in 2022. Mortality was highest among males, adults aged 35–44, and Black or African American individuals. West Virginia, Alaska, Washington, Tennessee, and Oregon had the steepest increases, while New Jersey, Utah, New Hampshire, Maryland, and South Dakota showed the most stable or improving trends. Less punitive policy scores (r = 0.76, p = 0.011) and high proportionality of the criminal justice system (r = 0.41, p = 0.239) were correlated with rising trends in death rates, while harm reduction (r = −0.53, p = 0.112) and access to painkillers (r = −0.52, p = 0.118) showed negative correlations.
Conclusions: Opioid mortality increased nationally during the study period. Among the ten purposively selected states, higher policy scores for the Absence of Extreme Responses (i.e., less punitive) were associated with worsening mortality trends. Whereas higher policy scores for Harm Reduction and Access to Medicines were associated with more favorable mortality trends, although these associations were not statistically significant. This small, extreme-case study demonstrated the feasibility of conducting in-depth analyses of multiple drug policy domains and generated hypotheses for testing in a larger study including all U.S. states.
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BibTeX
@article{wang2026drug,
title = {{Drug policies and annual opioid overdose mortality in U.S. states with the five worst and five best trends between 2018 and 2023: an ecological study}},
author = {Yun-Ting Wang and Said Iftekhar Sadaat and Daniel Ciccarone and Mohammad Karamouzian and Ali Mirzazadeh},
journal = {Addictive behaviors reports},
year = {2026},
month = oct,
doi = {10.1016/j.abrep.2026.100760},
url = {https://europepmc.org/article/PMC/PMC13720621},
note = {CC BY},
}
RIS
TY - JOUR
TI - Drug policies and annual opioid overdose mortality in U.S. states with the five worst and five best trends between 2018 and 2023: an ecological study
AU - Yun-Ting Wang
AU - Said Iftekhar Sadaat
AU - Daniel Ciccarone
AU - Mohammad Karamouzian
AU - Ali Mirzazadeh
PY - 2026
DA - 2026/10/22
JO - Addictive behaviors reports
DO - 10.1016/j.abrep.2026.100760
UR - https://europepmc.org/article/PMC/PMC13720621
AB - Purpose: To examine state-level opioid overdose mortality trends in the United States and assess their association with drug policy environments. Methods: This ecological study analyzed opioid-related overdose death data from 2018 to 2023 for all U.S. states using CDC WONDER. Linear regression estimated state-level mortality trends. The five states with the steepest increases and five with the most stable or improving trends were identified. Drug policies for these ten states were reviewed using the Global Drug Policy Index and correlated with mortality trends. Results: Opioid overdose deaths totaled 405,682 nationally, with the crude death rate peaking at 29.8 per 100,000 in 2022. Mortality was highest among males, adults aged 35–44, and Black or African American individuals. West Virginia, Alaska, Washington, Tennessee, and Oregon had the steepest increases, while New Jersey, Utah, New Hampshire, Maryland, and South Dakota showed the most stable or improving trends. Less punitive policy scores (r = 0.76, p = 0.011) and high proportionality of the criminal justice system (r = 0.41, p = 0.239) were correlated with rising trends in death rates, while harm reduction (r = −0.53, p = 0.112) and access to painkillers (r = −0.52, p = 0.118) showed negative correlations. Conclusions: Opioid mortality increased nationally during the study period. Among the ten purposively selected states, higher policy scores for the Absence of Extreme Responses (i.e., less punitive) were associated with worsening mortality trends. Whereas higher policy scores for Harm Reduction and Access to Medicines were associated with more favorable mortality trends, although these associations were not statistically significant. This small, extreme-case study demonstrated the feasibility of conducting in-depth analyses of multiple drug policy domains and generated hypotheses for testing in a larger study including all U.S. states.
SN - 2352-8532
ER -