Jon M. Hager and John S. Batchelder
University of North Georgia
Abstract
This paper reviews a variety of factors associated with differences in accidental deaths over a four-year period in Fulton County, Georgia. Along with race and biological sex, this analysis examines the age of the decedent whose cause of death included fentanyl. Data are plentiful that demonstrate the disparity between Caucasians and members of racial minority groups concerning the negative impact of fentanyl. This study expands on that research to include biological sex and age-of death among accidental deaths in Fulton County, Georgia. The findings show a statistically significant effect in fentanyl deaths between men and women, and between age groups categorized as “45 and older” and “under 45.” However, the results were inconclusive between persons of Caucasian background and non-Caucasians. Our findings punctuate the need for further research, and we recommend the use of community-based interventions that address these disparities.
Georgia Fentanyl Deaths: An Examination of Demographic Disparity in Racial Background, Age-group, and Biological Sex
Introduction
The Centers for Disease Control and Prevention (CDC) has repeatedly warned of an escalating trend in opioid-deaths starting around 2013, with an alarming rise of 18 times more synthetic (illicitly manufactured) opioid overdose deaths by 2020 (CDC, 2022). There was a 38% increase in these deaths from 2018 to 2019, and then the escalation continued, among all racial demographic groups, between 2020 and 2021 (CDC, 2022). Several factors have contributed to this increase; to include “potentially inappropriate prescribing practices” (PIPPs) but most signs point to challenging social conditions. Researchers are now requesting more studies on the demographic factors associated with this escalation to ensure that equitable policies and prevention programs are developed (Johnson et al., 2025). This study investigates the specific damage inflicted by fentanyl, both pharmaceutical and illicitly manufactured fentanyl (IMF), and its impact on persons whose manner of death was found to be “accidental.” Measured here is the demographic disparity among Georgia decedents.
Literature Review
Illicitly manufactured fentanyl is readily available and has claimed most fentanyl-related harm in the United States. U.S. Customs and Border Protection (CBP) (2023) reported the increase of fentanyl trafficked across the southern United States border corresponds directly with the increase in the number of accidental deaths. The CBP (2023) seized a total 14,700 pounds of fentanyl in 2022 and 17,200 pounds in 2023, an increase which they attribute to a cooperative effort involving China, India, and Mexico, who all are responsible for the increase of trafficked fentanyl into the United States.
The present study focused on fentanyl-related deaths in Fulton County, Georgia. Fulton County is the largest (528 square miles) and the most populous (1.1 million) of the 159 counties in Georgia and represents approximately 10% of Georgia’s population. The largest city in Fulton County is Atlanta. The demographics by race in Fulton County include 42.5% Black, 39.3% White (non-Hispanic), 8.7% Asian, and 8.1% Hispanic/Latino (Fulton County Government, 2020). The Georgia Department of Public Health’s (2023) Online Analytical Statistical Information System (OASIS) recorded a total of 1,379 synthetic overdose deaths statewide in 2021 in Georgia. One hundred and forty-seven deaths can be attributed to Fulton County (10%). The next closest was Gwinnett County with a total of 117 (8%).
National Studies
Fentanyl deaths are researched geographically at the national, regional, and local levels; many studies investigated racial disparities among decedents. From 2013 to 2020 in the United States, D’Orsogna et al. (2023) examined drug overdose deaths by race, biological sex, and geography. The specific drugs of concern for the study were psychostimulants, heroin, natural and semi-synthetic opioids, and synthetic opioids (fentanyl). The African American population, (male and female) surpassed the Caucasian population for fentanyl deaths nationwide. The most prominent racial disparity was evident in Washington D.C. where 134 per 1,000 Black males was 9.4 times greater than White males whose overdose death was due to fentanyl.
Furr-Holden et al. (2020) compared national trends of opioid-involved death between African Americans and Caucasians from 1999 to 2018. The authors examined data from the CDC and identified three different waves. Caucasians had an increase in opioid-related deaths from 1999 to 2006 (wave 1), and 2007 to 2013 (wave 2), but not from 2013 to 2018 (wave 3). During wave 3, a period identified by the CDC as being the introduction of illicitly manufactured fentanyl, the annual percentage of increase was greater for African Americans than Caucasians. It was during wave 3 that the CDC noted the proliferation of illicitly manufactured fentanyl. That introduction points to one explanation for how African Americans are now outpacing Caucasians in the United States for opioid-related deaths (Johnson et al., 2025).
The reduction in cost and increasing availability are offered as explanations for how the abuse of opioids has transitioned from prescription opioids to heroin, and now to fentanyl (Hoopsick et al., 2021). Those authors examined multiple demographics at the national level to account for differences by race, sex, and age, to better understand opioid overdose mortality rates. They discovered the greatest increase for synthetic (fentanyl) opioid overdose was for Black males.
Regional Studies
The National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMSHA) established what came to be known as “HEALing Communities” in 2019, located in Ohio, Massachusetts, New York, and Kentucky (SAMSHA, 2023). Evidence-based strategies were used to identify any existing racial disparities related to opioid overdose deaths (Larochelle et al., 2021). They calculated the overdose rates in 67 HEALing communities, comparing Caucasians to each racial group. Findings demonstrated a 40% increase in opioid overdose deaths for African Americans relative to Caucasians, while there were no statistically significant changes among other racial demographic groups. The authors concluded an overall leveling of opioid-related deaths, but an increase was observed for African Americans (Larochelle et al., 2021).
Racial background is frequently determined to be a contributing factor for disparity in fentanyl overdose deaths, but other factors are under investigation as well, such as geography (Gondre-Lewis et al., 2023). The authors showed that although the opioid epidemic was originally thought to be predominately a rural issue, it is now impacting the urban population as well. To account for the interaction between geography and race, Gondre-Lewis et al. (2023) measured trends in urban settings between African Americans and Caucasians in “hotspots” of opioid overdose deaths: Maryland, Illinois, Michigan, Pennsylvania, and Washington D.C. Reports from the Chief Medical Examiners and Departments of Health showed the overdose deaths among African Americans exceeded Caucasians by four to six-fold from 2013 to 2020. That finding is consistent with Hoopsick et al. (2021) described in wave 3 above where fentanyl and heroin were the greatest contributors to deaths of African Americans. Their findings show the disparity was accelerated by the COVID-19 pandemic in 2020, and suggested solutions to overcome the disparity by improving social and political resources (Gondre-Lewis, 2023).
According to Wu et al. (2022), there was evidence suggesting a shift in the race of victims of drug overdose in Connecticut. Prior to 2012, Black, and Latino communities experienced lower opioid overdose deaths, but that distribution took a dramatic swing between 2012 and 2019 (wave 3). The specific demographic groups examined were Caucasian, Latino, African American and Asian / Pacific Islanders. Other variables included age groups, and drug-type (fentanyl, heroin, cocaine, and other opioids). A regression analysis showed a significant increase in drug-overdose fatality among African Americans across Connecticut from 2012 to 2019: Caucasian rate held steady at 4.6 per 100,000 while the African American rate rose to 6.0 per 100,000 during the same timeframe (the Hispanic overdose fatality rate was 3.0 and for Asians or Pacific Islanders was .6).
Local Studies
The third wave of the opioid crisis includes the introduction of fentanyl and its analogs. Consistent with the regional findings, fentanyl has contributed to the largest number of deaths among African Americans. Banks et al. (2023b) reviewed opioid overdose deaths between what the authors called the pre-fentanyl era (2011 to 2015) and the fentanyl era (2016 to 2021) in St. Louis, Missouri using data from the medical examiners’ offices. The total number of deaths during the timeframe of the study was 4,420 and the authors found a more densely cluster of Black decedents versus White decedents, especially in areas heavily populated by African Americans. Phalen et al. (2018) estimated trends for fentanyl-related overdose deaths in Indianapolis using coroner data from full toxicology screens in Marion County, Indiana. Starting in 2010, the percentage of overdose deaths grew from below 15% to nearly 50% in 2017. In 2010, Blacks had the lowest number of overdose deaths but continued to increase and eventually surpassed the number of White deaths, mirroring the trends mentioned above. The coroner recorded a total of 1,583 deaths between January 1, 2010 and April 30, 2017. The model examined fentanyl-related overdoses including age, race, biological sex, and zip code as independent variables. Of those 1583 recorded overdose deaths, 379 identified fentanyl as a contributing cause.
Nesoff et al. (2020) examined the geographic distribution of fentanyl-related overdose deaths in comparison to non-fentanyl-related deaths between 2014 and 2018 using data from Cook County, Illinois, Medical Examiner’s Office. That study found significant differences at both the individual and neighborhood levels, noting that neighborhood deprivation was a significant predictor. In keeping with the expected pattern, Nesoff et al. (2020) found that Blacks and Latinos had significantly higher odds of a fentanyl-related death.
The above literature, discussing national level data and regional / local sources, reveals that the most common factors, race, age, and biological sex, continue to serve as statistically significant predictors of variability in opioid deaths. In keeping with the continued calls for more research, the purpose of this examination is to measure the strength of each of those factors in a specific context: Deaths involving fentanyl.
Methodology
Illicitly manufactured fentanyl (IMF) comprises the majority of fentanyl-involved deaths, whereas pharmaceutical manufactured fentanyl is not far behind. However, Fulton County death data does not distinguish whether the death was related to pharmaceutical or illicitly manufactured fentanyl. Therefore, this study is centered on if the accidental death was in some way attributable to fentanyl (irrespective of the decedent’s source) and the related factors associated with that death.
The dataset (N = 1803) from the Fulton County Death Investigator’s file records over a four-year period included 1176 males and 604 females (five subjects were not identified by biological sex). From the original 1803 subjects, the cause of death was available on 1273 subjects. Among those 1273, the manner of death varied between accident, homicide, natural, suicide, or undetermined. Subjects whose manner of death was determined to be “accidental” were used for this study (N = 769). The dependent variable was cause of death (“included fentanyl” or “no fentanyl included”). The independent variables were biological sex (labeled “male” or “female”), age-group (“under age 45” or “age 45 and older”), and race (Hispanic, Black, Asian, and White).
By race, there were 336 White subjects (Caucasian) and 402 Black subjects, 19 Hispanic subjects, and 7 Asian subjects (non-Caucasian). Race was recoded dichotomously as “white” or “nonwhite” owing to the sparsity of subjects in the Hispanic and Asian categories). The final data set included 544 males and 225 females, with 427 subjects under age 45, and 342 age 45 or older. The dependent variable was grouped dichotomously by those who died while using fentanyl (n = 543), or those who died absent from any fentanyl use (N = 226)..
Results
The independent variable of principal concern for the purpose of this study was age of the decedent. The number of persons whose death involved fentanyl were higher than those who died absent fentanyl use, and that difference was statistically significant, χ2(1,N = 769) = 43.683, p.< .05. Although the differences between age groupsdid not reveal a notable effect size, the proportion those who died from fentanyl under age 45 (80%), and over age 45 (58%) does not leave doubt as to the question of age as an important factor. In other words, accidental deaths were more likely to occur among persons using fentanyl in both age groups and was particularly risky for those under age 45. This statistically significant finding underscores the notion that the risk of death is greatly elevated when someone uses fentanyl and is not indiscriminate of the user’s age.
We next examined the distribution of the accidental deaths in Fulton County by biological sex. Again, both male and female decedents had a much greater likelihood of accidental death when the risk-factor of fentanyl was present χ2(1,N = 769)= 10.786, p. < .05. The data demonstrated a distinct and statistically significant difference in the probability of an accidental death occurring when fentanyl was involved. The probability for male decedents was 74% and for female decedents was 62%.
Racial background of the decedents was the third and final factor under consideration in this study. In contrast to multiple previous studies at the national, regional and local levels, there were no statistically significant differences in accidental death when decedents were categorized by race among these Fulton County subjects. Statistically significant differences were not found in the dependent variable, death caused by fentanyl, among Caucasian and non-Caucasian categories χ2(1,N = 769) = 2.420, p. > .05. The dataset was originally categorized into 4 groupings according to race and then recoded dichotomously between non-Caucasians and Caucasians because of extremely low representation among Latino and Asian decedents. The difference in fentanyl deaths among Caucasians (74%) and non-Caucasians (68%) was not statistically different than those whose death did not involve fentanyl.
Conclusion
This paper has discussed the issues surrounding racial disparities related to fentanyl deaths at the national level, the regional level, and at the local level in the United States. The opioid crisis in general is a complex issue throughout the literature, with emphasis on the influence of geography, age, race and biological sex (particularly regarding any disparity in those factors). Geographically, fentanyl deaths are trending from the rural to the urban areas. By race they are victimizing the Black population in increasing numbers, who are now surpassing the number of White victims (Friedman & Hansen, 2022). However, our findings reveal that, at least among accidental deaths in Fulton County, Georgia, race differences did not rise to the level of statistical significance.
One possible reason for this is the population make-up in Fulton County is racially represented equally with the suburban population having a higher concentration of Caucasians and the urban population more Blacks, thus canceling out any differences. Powell (2021) concluded that the distribution and availability of opioids affect racial groups differently owing to the supply-side shock of Oxycontin. The present study found no racial differences in the make-up of this sample that consisted equal proportions.
Prior to the shift of fentanyl deaths to the urban areas, the highest concentration of deaths during the 2000s was in low-income White communities. Friedman and Hansen (2022) echoed those findings reporting the number of deaths of Black individuals exceed the number of White individuals by nearly 20%, and that Native American Indians have the highest rate of deaths, exceeding White deaths by 30%. This is an area of investigation that clearly merits further research.
Solving the disparity issues in fentanyl deaths among those who vary by biological sex and age, much like the differences among racial groups, is in understanding the underlying problems. Economic and community distress are frequently identified as saliant underlying problems, along with low education, high unemployment, housing vacancy, and the lack of Medicaid expansion (Friedman & Hansen, 2022). Therefore, expanding resources provided to deprived neighborhoods may help to ameliorate the scourge of fentanyl deaths to racial categories, and help level the playing field where disparities exist among age and sex categories as well. Additionally, as suggested by Banks et al. (2023a), volunteers are needed to provide outreach-base services. Focus groups consisting of peer advocates and community health workers can identify core themes and driving forces behind gaps in safety, security, and stability. The goal, in short, is to eliminate social service barriers..
References
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John Stuart Batchelder is a Professor of Criminal Justice at University of North Georgia who specializes in statistical analysis and corrections. He received his doctorate in Adult Education from the University of Southern Mississippi. His research interests focus on prison education and intervention and quantitative methodologies.
Jon M. Hager is an Assistant Professor of Criminal Justice at the University of North Georgia specializing in forensic science and specifically death investigations. He received his doctorate in Psychology with a concentration in Criminal Justice from the University of the Rockies. His current research interests include forensic science and death investigations.