The overdose map and the enforcement map are not identical, but they overlap substantially. The states where people are dying at the highest rates are the states where the investigative resources have been most concentrated.
Drug overdose deaths, the majority of which involve opioids in some form, have become the leading cause of accidental death in the United States, surpassing motor vehicle accidents in annual mortality. The Centers for Disease Control and Prevention tracks overdose deaths by state, by drug type, and by demographic characteristic. Its data reveals patterns that are both geographically concentrated and rapidly evolving as the composition of the illicit drug supply shifts from pharmaceutical opioids and heroin toward illicitly manufactured fentanyl and, more recently, combinations of fentanyl with stimulants such as methamphetamine.
The Current Highest-Rate States
West Virginia has led the nation in drug overdose death rates for the majority of the past two decades, with a rate that has consistently been two to three times the national average. The state’s combination of economic factors, geographic isolation, limited healthcare access, and the historical concentration of opioid prescribing in industries associated with chronic pain has produced overdose rates that reflect a public health crisis of unusual severity.
Kentucky, Ohio, Tennessee, and Pennsylvania consistently appear among the states with the highest overdose death rates. Ohio’s rate has been driven substantially by fentanyl-related deaths, and the state has at various points led the nation in the absolute number of overdose deaths even when its rate, accounting for population, has been exceeded by smaller Appalachian states. Pennsylvania’s overdose crisis has been concentrated in its urban centers, particularly Philadelphia, which experienced an epidemic of deaths associated with the combination of fentanyl with the veterinary tranquilizer xylazine, a combination that does not respond to naloxone reversal in the same manner as opioid-only overdoses.
New England’s Disproportionate Impact
New Hampshire has at various points led the nation in per-capita overdose death rates, a distinction that reflects the state’s small population combined with a drug supply that became saturated with high-potency fentanyl compounds at an earlier stage than many other states. Vermont and Maine have similarly reported per-capita death rates that exceed those of larger states more associated with the opioid crisis in public perception.
The New England states’ experience with fentanyl-related deaths has been instructive for the country’s understanding of how the opioid crisis evolves. The transition from pharmaceutical opioid dependence to heroin to fentanyl occurred in New England with a clarity and speed that preceded similar transitions in other regions and that informed the public health and law enforcement responses deployed elsewhere.
States With Rapidly Increasing Rates
The states where overdose death rates have increased most rapidly in recent years are not necessarily the states historically associated with the opioid crisis. States in the West and South, including California, Nevada, Colorado, and Louisiana, have experienced substantial increases in overdose death rates associated with the spread of illicitly manufactured fentanyl into drug markets that previously had less exposure to high-potency synthetic opioids. The geographic expansion of fentanyl-related mortality reflects the supply chain dynamics of the illicit drug trade rather than any characteristic of the affected states’ healthcare systems.
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(212) 300-5196California’s experience is particularly notable because its size and the diversity of its drug markets mean that its absolute number of overdose deaths is among the highest in the country even when its per-capita rate is lower than that of Appalachian states. The DEA’s California enforcement has addressed both the trafficking organizations responsible for fentanyl distribution and the prescribing and dispensing practices that contributed to the pharmaceutical opioid dependence that preceded the fentanyl transition.
The Fentanyl Transition and Its Enforcement Implications
The shift from pharmaceutical opioids to illicitly manufactured fentanyl as the primary driver of overdose deaths has significant implications for the DEA’s enforcement priorities. The pharmaceutical prescribing enforcement that dominated the DEA’s opioid strategy during the 2010s remains active, but it operates alongside a substantially expanded trafficking enforcement effort directed at the Mexican cartels and domestic distribution networks responsible for the fentanyl supply.
The practitioner who prescribes pharmaceutical opioids in the current environment is prescribing in a context where the illicit drug supply is more potent and more dangerous than it was during the period when the practitioner’s prescribing habits were established. A patient who supplements a pharmaceutical opioid prescription with illicitly obtained drugs is at substantially greater risk of overdose than the same patient would have been a decade ago, and the prescriber whose patient dies of a fentanyl overdose while holding a legitimate opioid prescription is a prescriber whose records may be examined in the subsequent investigation.
Todd Spodek
Lead Attorney & Founder
Featured on Netflix's "Inventing Anna," Todd Spodek brings decades of high-stakes criminal defense experience. His aggressive approach has secured dismissals and acquittals in cases others deemed unwinnable.
The overdose death data that the CDC publishes annually is the data that drives DEA enforcement priorities, congressional appropriations, and public health policy. The states that appear at the top of the overdose death rankings are the states that will receive the most investigative attention in the subsequent enforcement cycle. The practitioners in those states who have not yet been investigated are practitioners whose risk of investigation reflects the environment they practice in, not only the character of their prescribing.
The Data’s Limitations
Overdose death data has limitations that affect its use both in public health analysis and in legal proceedings. Death certificates are classified by the medical examiner or coroner, who may not always have access to complete toxicology findings. The classification of a death as opioid-related may not identify the specific opioid or the source of the opioid found in the decedent’s system. A practitioner whose patient dies of an overdose involving a combination of pharmaceutical and illicit opioids may face investigation even where the pharmaceutical opioids did not cause the death.
The connection between a specific prescriber and a specific overdose death, when it forms the basis of a criminal prosecution, must be established through evidence that goes beyond the presence of a controlled substance prescription in the decedent’s records. The death-resulting enhancement under federal law, which can increase the maximum sentence to twenty years or impose a mandatory minimum of twenty years in cases where death results from the use of a distributed controlled substance, requires proof that the drug the defendant distributed was the cause of the death. Establishing that causal connection is a contested issue in prosecutions where the decedent’s toxicology reveals multiple substances.
