Extreme vulnerability to overdose mortality: Intersections of detailed race/ethnicity, educational attainment, age, sex, and nativity

Background: This study examined which specific sociodemographic groups are most affected by drug overdose deaths in the United States (US). Methods: The study consisted of a cross-sectional analysis of US death certificate data (2018–2023) from 512,198 drug overdose deaths. We calculated drug overdose mortality rates and proportionate mortality for subpopulations formed based on the concurrent intersection of detailed race/ethnicity, sex, age, nativity, and educational attainment. Results: In the US, 2018–2023, of all subpopulations examined, male foreign/territory-born Puerto Rican Americans ages 35–49 with a high school education or lower experienced the highest estimated drug overdose mortality rate (261.9 per 100,000) and highest overdose proportionate mortality (with overdoses accounting for 42.8 % of all deaths in the group). Following this group, the highest overdose mortality rates (per 100,000) were observed in: male US-born Non-Hispanic (NH) American Indian/Alaska Native Americans ages 35–49 with a high school education or lower (235.2); male foreign/territory-born Puerto Rican Americans ages 50–64 with a high school education or lower (218.4); and male US-born NH Black Americans ages 50–64 with a high school education or lower (213.2). Elevated overdose proportionate mortality was observed in female US-born NH White-and-Black Americans ages 21–34 with a high school education or lower and male US-born South Americans ages 21–34 with a high school education or lower (with overdoses accounting for 42.2 % and 42.1 % of all deaths in these groups, respectively). Conclusions: Low educational attainment intersects with risks related to age, sex, nativity, and racial/ethnic identification to shape disparities in US drug overdose deaths.