National trends and racial disparities

The data presented in this section details the national growth of mass incarceration in local jails and the simultaneous, tragic escalation of deaths resulting from overdose. You can read more about the data sources here.

Jail incarceration and overdose deaths are deeply entwined and both have roots in America’s longstanding war on drugs and use of the criminal legal system to target Black people and other communities of color. Despite similar levels of drug use compared to white people, Black people and other people of color have been disproportionately criminalized for drug-related offenses; decades of punitive, enforcement-focused policies have had devastating impacts on these communities.[]Elizabeth Hinton, LeShae Henderson, and Cindy Reed, An Unjust Burden: The Disparate Treatment of Black Americans in the Criminal Justice System (New York: Vera Institute of Justice, 2018), https://perma.cc/9DRC-AKGH. Jason Tan de Bibiana, Charlotte Miller, Leah Pope, Susan Stellin, Jim Parsons, and David Cloud, Changing Course in the Overdose Crisis: Moving from Punishment to Harm Reduction and Health (New York: Vera Institute of Justice, 2020), https://www.vera.org/downloads/publications/changing-course-in-the-overdose-crisis.pdf. For statistics on the prevalence of drug use among different racial and ethnic groups see Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Behavioral Health Statistics and Quality, Results from the 2018 National Survey on Drug Use and Health: Detailed Tables (Rockville, MD: SAMHSA, 2020), Table 1.22B, https://perma.cc/R7BU-JBU2. Today, of the almost 2.3 million people incarcerated in America’s federal and state prisons, local jails, juvenile correctional facilities, and immigration detention facilities, one in five people are locked up for drug offenses.[]Wendy Sawyer and Peter Wagner, Mass Incarceration: The Whole Pie 2020 (Northampton, MA: Prison Policy Institute, 2020), https://www.prisonpolicy.org/reports/pie2020.html. Data from 2007 to 2009’s National Inmate Surveys estimated that 58 percent of people incarcerated in state prisons and 63 percent of people serving sentences in jails met the criteria for a substance use disorder.[]Bronson et al. Jessica Stroop, Stephanie Zimmer, and Marcus Berzofsky, Drug Use, Dependence, and Abuse Among State Prisoners and Jail Inmates, 2007-2009 (Washington, DC: Bureau of Justice Statistics, 2017), https://perma.cc/ZE6J-RT25.

Source: Overdose death rate analysis provided to Vera by Professor Matthew Kiang, https://github.com/mkiang/opioid_trends/tree/vera-analysis.

See Methodology and data sources for more detail.

Just as punitive responses to drug use have driven incarceration, substantial evidence suggests that incarceration is associated with increased risk for overdose death.[]Elias Nosrati, Jacob Kang-Brown, Michael Ash, et al., “Economic Decline, Incarceration, And Mortality From Drug Use Disorders In The USA Between 1983 And 2014: An Observational Analysis,” Lancet Public Health 4, no.7 (2019), e326-33, https://perma.cc/75LT-TARA. Also see Paul J. Joudrey, Maria R. Khan, Emily A. Wang, et al., “A Conceptual Model for Understanding Post-Release Opioid-Related Overdose Risk.” Addiction Science & Clinical Practice 14 (2019), 17, https://perma.cc/F9UB-3NZU. Research has confirmed that overdose is the leading cause of death among people recently released from prisons, as well as the third leading cause of deaths in custody in U.S. jails.[]See Ingrid A. Binswanger, Patrick J. Blatchford, Shane R. Mueller, and Marc F. Stern, “Mortality After Prison Release: Opioid Overdose and Other Causes of Death, Risk Factors, and Time Trends From 1999 to 2009,” Annals of Internal Medicine 159, no. 9 (2013), 592–600; Ingrid A. Binswanger, Marc F. Stern, Richard A. Deyo, et al., “Release from Prison—A High Risk of Death for Former Inmates,” New England Journal of Medicine 356, no. 2 (2007), 157–65, https://perma.cc/L49X-7MZ7; Kevin Fiscella, Margaret Noonan, Susan H. Leonard, et al., “Drug- and Alcohol-Associated Deaths in U.S. Jails,” Journal of Correctional Health Care 26, no. 2 (2020), 183–93; and E. Ann Carson and Mary P. Cowhig, Mortality in Local Jails, 2000–2016—Statistical Tables (Washington, DC: Bureau of Justice Statistics, 2020), https://perma.cc/W8GC-A9N8.

The ways that incarceration contributes to increased overdose risk, particularly for people using opioids, include tolerance loss during periods of abstinence, limited access to Medication-Assisted Treatment (MAT) and naloxone while incarcerated and when released, and disruptions to health care and social supports.[]Paul J. Joudrey, Maria R. Khan, Emily A. Wang, et al., “A Conceptual Model for Understanding Post-Release Opioid-Related Overdose Risk.” Addiction Science & Clinical Practice 14 (2019), 17, https://perma.cc/F9UB-3NZU. Also see: Lauren Brinkley-Rubinstein, Nickolas Zaller, Sarah Martino, et al., “Criminal Justice Continuum for Opioid Users at Risk of Overdose.” Addictive Behaviors 86 (2018), 104–10. Though periods of jail incarceration are typically much shorter than prison sentences, they can profoundly disrupt the lives of people in similar ways.

The days and weeks following release from incarceration are also a particularly high-risk period for overdose death. A seminal study in Washington State found that, in the two weeks following their release, people who had been incarcerated in state prisons were 129 times more likely to die from an overdose compared to the general public.[]Ingrid A. Binswanger, Marc F. Stern, Richard A. Deyo, et al., “Release from Prison—A High Risk of Death for Former Inmates,” New England Journal of Medicine 356, no. 2 (2007), 157–65, 161, https://perma.cc/L49X-7MZ7 A recent study from North Carolina state prisons corroborated this heightened risk, finding that formerly incarcerated people were 40 times more likely to die of an opioid overdose two weeks post-release.[]Shabbar I. Ranapurwala, Meghan E. Shanahan, Apostolos A. Alexandridis, et al., “Opioid Overdose Mortality Among Former North Carolina Inmates: 2000–2015,” American Journal of Public Health 108, no. 9 (2018), 1207–13, 1207.

Although reducing the number of people in jails and prisons is not a panacea for the overdose crisis, investments that increase incarceration are almost certainly not going to reduce overdose deaths. A previous Vera project on the price of jails found that, across 35 jail jurisdictions spanning 18 states, the average annual cost to incarcerate someone for a year was approximately $46,000.[]Christian Henrichson, Joshua Rinaldi, and Ruth Delaney, The Price of Jails: Measuring the Taxpayer Cost of Local Incarceration (New York: Vera Institute of Justice, 2015), https://www.vera.org/publications/the-price-of-jails-measuring-the-taxpayer-cost-of-local-incarceration. The amount $46,000 is a rounded value of author calculations, representing the average annual cost per incarcerated person among all survey respondents. This represents a considerable cost to local taxpayers that communities could otherwise be spending on health and social service needs. One forthcoming study of county-level data from 1999 to 2015 found that increased community-based substance use treatment capacity was associated with decreases in both jail admissions and overdose deaths.[] Marilyn Sinkewicz and Leah Pope, “Jail Incarceration, Drug Overdose Mortality, and Drug Treatment: New Evidence from US County-level Data, 1999-2015,” (Working paper, 2020). However, how these relationships work is not yet clear. For example, the authors hypothesize that “Increases in treatment facilities may be a proxy for broader investments in public health, community resources, and alternatives to criminal justice involvement,” which in turn may contribute to fewer overdose deaths and less incarceration.[]To elaborate on limitations and the need for additional research, Sinkewicz and Pope state that “The same communities that are building additional treatment capacity may also be taking a multipronged approach to drug use that collectively leads to fewer jail admissions and fewer overdose deaths. This approach aligns with arguments that the overdose crisis requires a comprehensive and integrative approach to the social determinants of health. However, these hypotheses and others require further testing before causal statements can be made. The ability to explore these data is relatively new. Researchers are working to understand the causal pathways, but more data and research is needed.” Sinkewicz and Pope, “Jail Incarceration.” More research is needed to understand these pathways and their implications for policy decisions.

Explore the graphs below for more detail on the growth of overdose deaths and jail incarceration nationwide, or click here to see how these trends have played out in your state.

Trends in overdose death by urbanicity and race

From 2014 to 2018, more than 300,000 people in America lost their lives to a drug overdose—a time period that saw the sharpest growth in overdose deaths in more than 30 years.[] Holly Hedegaard, Arialdi Miniño, and Margaret Warner, Drug Overdose Deaths in the United States, 1999–2018 (Hyattsville, MD: National Center for Health Statistics, 2020), https://perma.cc/ES6Y-V62N (data available at https://perma.cc/8UPY-ZAGH). More lives were lost in 2017 to drug overdose than either influenza and pneumonia, suicide, or motor vehicle traffic accidents.[]Kenneth Kochanek, Sherry Murphy, Jiaquan Xu, and Elizabeth Arias, “Deaths: Final Data for 2017,” National Vital Statistics Reports 68, no. 9 (Hyattsville, MD: National Center for Health Statistics 2019), Table 6, https://perma.cc/4JF8-7X9W. Until recently, most substance use-related deaths had been connected to long-term, chronic alcohol and tobacco use. Although alcohol and tobacco continue to claim more lives than other drugs, the lethality of opioids, and synthetic opiates such as fentanyl, is unprecedented.[]“An estimated 88,000 people… die from alcohol-related causes annually, making alcohol the third leading preventable cause of death in the United States. The first is tobacco, and the second is poor diet and physical inactivity.” National Institute on Alcohol Abuse and Alcoholism, “Alcohol Facts and Statistics,” February 2020, https://perma.cc/6J77-CB8V; and Hedegaard et al., Drug Overdose Deaths 1999–2018, 1 “The rate of drug overdose deaths involving synthetic opioids other than methadone (drugs such as fentanyl, fentanyl analogs, and tramadol increased by 10% from 9.0 in 2017 to 9.9 in 2018.”. In 2018, opioids were involved in nearly 70 percent of all overdose deaths, most of which involved synthetic opioids.[] Centers for Disease Control and Prevention, “Drug Overdose Deaths,” https://perma.cc/54XH-D6YQ. Preliminary data for 2019 and 2020 suggest that drug overdose deaths have continued to rise, with synthetic opioids as well as methamphetamine and cocaine being major contributors.[]FB Ahmad, LM Rossen, and P Sutton, “Provisional Drug Overdose Data,” database (Washington, DC: Centers for Disease Control and Prevention, National Center for Health Statistics), https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm; and Josh Katz, Abby Goodnough, and Margot Sanger-Katz, “In Shadow of Pandemic, U.S. Drug Overdose Deaths Resurge to Record,” New York Times, July 15, 2020, https://www.nytimes.com/interactive/2020/07/15/upshot/drug-overdose-deaths.html.

Overdose death rates have increased across all types of jurisdictions since 2000, though, as the chart below shows, the overall rates remain higher in urban compared to rural counties.

There is also variation in the types of drugs used: according to CDC data from 2017, heroin, synthetic opioids (e.g., fentanyl), and cocaine were involved in more urban overdose deaths, whereas natural and semisynthetic opioids (e.g., oxycodone, hydrocodone, morphine, and codeine) and stimulants (e.g., methamphetamine) were involved in more rural overdose deaths.[]Holly Hedegaard, Arialdi Miniño, and Margaret Warner, Urban–Rural Differences in Drug Overdose Death Rates, by Sex, Age, and Type of Drugs Involved, 2017 (Hyattsville, MD: National Center for Health Statistics, 2019), https://perma.cc/7L26-AXQN.

In 2018, overdose deaths were greatest among Native American and white people in the United States. The national rates, however, obscure considerable local variation in the rates of overdose deaths by race and ethnicity. As the chart below shows, Native American and white people had nearly equal overdose death rates of 25.67 and 26.91 per 100,000 residents in 2018, consistent with similar trends between these two groups over the previous 18 years. However, during the previous five years, Black Americans experienced rapidly increasing overdose rates, growing from 9.58 per 100,000 residents in 2013 to 21.04 per 100,000 residents in 2018—an increase of about 120 percent.

Source: Overdose death rate analysis provided to Vera by Professor Matthew Kiang, https://github.com/mkiang/opioid_trends/tree/vera-analysis.

See Methodology and data sources for more detail.

In 2018, the overdose death rate for Black Americans was higher than the rate for white Americans in Illinois, Michigan, Minnesota, Missouri, Washington State, West Virginia, and Wisconsin.[]Kaiser Family Foundation, “Opioid Overdose Deaths by Race/Ethnicity: 2018,” https://perma.cc/RDJ7-YB4E. In Minnesota in 2019, Native Americans were seven times more likely to die of overdose than white people, and in 2018 in New York City, Latinx people had the highest rate of overdose death compared to other groups.[]Mary DeLaquil, Differences in Rates of Drug Overdose Deaths by Race (St. Paul, MN: Minnesota Department of Health, 2020), 1, 6, Chart 2, https://perma.cc/9APN-2MB4; and New York City Department of Health and Mental Hygiene, Epi Data Brief No. 116 (New York: NYC Health, 2019), 2, https://perma.cc/9ZQW-FBDS. Rising rates of synthetic opioid use among Black and Latinx Americans may partly explain these more recent trends.[]Agency for Healthcare Research and Quality, Blacks Experiencing Fast-Rising Rates of Overdose Deaths Involving Synthetic Opioids Other Than Methadone (Rockville, MD: Agency for Healthcare Research and Quality, 2020), https://perma.cc/9ZJF-WQUT; and Merianne Rose Spencer, Margaret Warner, Brigham A. Bastian et al., “Drug Overdose Deaths Involving Fentanyl, 2011–2016,” National Vital Statistics Reports 68, no. 3 (2019), https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_03-508.pdf. Previous research has also identified structural and systemic racism in access to resources for prevention, harm reduction, and treatment—including racial and ethnic disparities in access to medication-assisted treatment for opioid use disorders and prescribing patterns for opioid pain medications.[]See Helena Hansen, Carole Siegel, Joseph Wanderling et al., “Buprenorphine and Methadone Treatment for Opioid Dependence by Income, Ethnicity and Race of Neighborhoods in New York City,” Drug and Alcohol Dependence 164 (2016), 14–21, https://perma.cc/6D2F-BWLS; Leila M. Vaezazizi, Julie Netherland, and Helena Hansen, “The Opioid Epidemic: Social Determinants and Health Inequities,” in The American Opioid Epidemic: From Patient Care to Public Health, edited by Michael T. Compton and Marc W. Manseau (Washington, DC: American Psychiatric Association Publishing, 2019), 116–19; and Jose A. Del Real, “Opioid Addiction Knows No Color, but Its Treatment Does,” New York Times, January 12, 2018, https://www.nytimes.com/2018/01/12/nyregion/opioid-addiction-knows-no-color-but-its-treatment-does.html. Also see Martha Bebinger, “What Explains The Rising Overdose Rate Among Latinos?” NPR, May 16, 2018, https://perma.cc/78PP-657W; and Sari Horwitz, Debbie Cenziper, and Steven Rich, “As Opioids Flooded Tribal Lands across the U.S., Overdose Deaths Skyrocketed,” Washington Post, June 29, 2020, https://www.washingtonpost.com/graphics/2020/national/investigations/native-american-opioid-overdose-deaths/.

Trends in jail incarceration by urbanicity and race

Mass incarceration has played out over a longer timescale than the current opioid overdose crisis, but its human impact is no less dramatic. Between 1980 and 2018, the average rate of incarceration in local jails increased by 193 percent, from 125 to 366 per 100,000 residents ages 15 to 64. The United States has had the highest levels of incarceration in the world for decades.[] Peter Wagner and Wendy Sawyer, States of Incarceration: The Global Context 2018 (Northampton, MA: Prison Policy Institute, 2018), https://perma.cc/MH72-JKX7 And although jail incarceration in some urban areas of the U.S. has plateaued and started to decline, as shown in the chart below, rates of jail incarceration have continued to increase in rural areas and small towns across America.[]Jacob Kang-Brown and Ram Subramanian, Out of Sight: The Growth of Jails in Rural America (New York: Vera Institute of Justice, 2017), 12, https://perma.cc/34ME-RRRT. In 2019, there were still more than 758,000 Americans in jails at any given time and, assuming jail admissions were consistent with 2017 figures, likely more than 10 million jail admissions over the entire year.[]Jacob Kang-Brown, Oliver Hinds, Eital Schattner-Elmaleh, and James Wallace-Lee, People in Jail in 2019 (New York: Vera Institute of Justice, 2019), 1, https://perma.cc/V8M6-XULN; and Zhen Zeng, Jail Inmates in 2017 (Washington, DC: BJS, 2019),1, https://perma.cc/CYP8-Q6QQ.

The ways that America’s long history of racism and oppression have continued through the policies and practices of the criminal legal system, disproportionately targeting and incarcerating Black Americans and other communities of color, have been well documented.[]Elizabeth Hinton, LeShae Henderson, and Cindy Reed, An Unjust Burden: The Disparate Treatment of Black Americans in the Criminal Justice System (New York: Vera Institute of Justice, 2018), https://perma.cc/9VV3-L36G. Despite similar rates of drug use, the most recent publicly available data compiled by Vera’s Arrest Trends tool shows that in 2014, Black people were an estimated 2.39 times more likely to be arrested for “drug abuse violations” than white people.[]The FBI’s Uniform Crime Report—which provides a national picture of arrest data submitted voluntarily by individual police agencies and is one major data source included in Vera’s Arrest Trends tool—defines “drug abuse” violations as the “violation of laws prohibiting the production, distribution, and/or use of certain controlled substances.” For more information, see Megan J. O’Toole and S. Rebecca Neusteter, “Data Sources and Methodology,” https://perma.cc/L4BT-BHFR; and U.S. Department of Justice, Federal Bureau of Investigation, Criminal Justice Information Services Division, “Offense Definitions,” https://perma.cc/F66L-WJEL. For statistics on the prevalence of drug use among Black and white people see SAMHSA, Results from the 2018 National Survey on Drug Use and Health, Table 1.22B, https://perma.cc/R7BU-JBU2. For Vera’s Arrest Trends tool and analysis of racial disparities in arrests, see https://arresttrends.vera.org/; and Rebecca Neusteter and Megan O’Toole, Every Three Seconds: Unlocking Police Data on Arrests (New York: Vera Institute of Justice, 2019), https://www.vera.org/publications/arrest-trends....

As shown in the chart below, even as racial disparities in jail incarceration for Black and Latinx people decreased from 2000 to 2015, as of 2015, Black people were still incarcerated at 3.45 times the rate of white people, Native Americans were incarcerated at 2.23 times the rate of white people, and Latinx Americans were incarcerated at 1.17 times the rate of white people.

Learn More

To understand trends in overdose death, jail incarceration, and racial disparities, Vera collected national and local data that can be explored using the tools below. Learn more about data used to compile these tools here. In addition, Vera reviewed state policies and conducted case studies of local responses to the overdose crisis in New Mexico and North Carolina to provide context for the numbers

Explore Local Data

To understand trends in overdose death, jail incarceration, and racial disparities, the Vera Institute of Justice (Vera) collected national and local data that can be explored using the tools below. Learn more about the data used to compile these tools. In addition, Vera reviewed state policies and conducted case studies of local responses to the overdose crisis in New Mexico and North Carolina to provide context for the numbers.