State-Level Excess Drug Overdose Mortality by Race/Ethnicity in the U.S., 2020–2023: A Population-Scaling Analysis During the COVID-19 Pandemic

Abstract Purpose: The COVID-19 pandemic coincided with worsening U.S. drug overdose mortality and widening racial and ethnic disparities. We estimated race/ethnicity–specific excess overdose deaths at the state level during 2020–2023 and examined how these burdens scale with population size. Methods: We analyzed annual overdose deaths from 2014–2023 for five racial/ethnic groups in 47 states and the District of Columbia. Pre-pandemic trends (2014–2019) were fit using a generalized growth model, and deaths exceeding projections in 2020–2023 were classified as excess deaths. Scaling was evaluated by regressing excess and total deaths on 2020 state population in log–log models and relating excess-death rates to social and behavioral indicators. Results: White populations experienced the largest absolute excess, peaking in 2021. Black populations showed minimal excess in 2020 but rose sharply in 2021–2022, nearly matching White deaths by 2023; Hispanic excesses were intermediate. Scaling analyses showed sublinear growth of Black deaths with population, while White and Hispanic deaths scaled approximately proportionally. Within-state rank tests indicated higher excess-death rates for Black than for White or Hispanic populations. Conclusions: Excess-mortality and scaling analyses reveal heterogeneous and inequitable overdose burdens across racial and ethnic groups during the pandemic and can inform equity-focused surveillance and prevention efforts.