Men Much More Prone to Drug Overdose Death Than Women

Men were significantly more vulnerable than women to overdose deaths involving opioid and stimulant drugs in 2020–2021, according to a new study analyzing data from across the United States.

The study, published in Neuropsychopharmacology, found that men had a two to three times greater rate of overdose mortality from opioids (like fentanyl and heroin) and psychostimulants (like methamphetamine and cocaine). The study was led by researchers from the Icahn School of Medicine at Mount Sinai in New York City and the National Institute on Drug Abuse (NIDA).

While we know that men use drugs at higher rates than women, the researchers found that this alone could not explain the gap in overdose deaths, noting that biological, behavioral, and social factors likely combined to increase the mortality risk for men. From 2020 to 2021, men had a rate of overdose mortality from opioids and psychostimulants that was two to three times greater than the overdose mortality rate for women, according to a recent study.

“Though men and women are being exposed to the modern, fentanyl-contaminated drug supply, something is leading men to die at significantly higher rates,” NIDA Director Nora Volkow, MD, said in a news release. “It may be that men use drugs more frequently or in greater doses, which could increase their risk of death, or there may be protective factors among women that reduce their risk of death compared to men. Understanding the biological, behavioral, and social factors that impact drug use and our bodies’ responses is critical to develop tailored tools to protect people from fatal overdose and other harms of drug use.”  

After controlling for sex-specific rates of drug misuse, researchers found that overdose death rates by sex for the following drugs were:

Synthetic opioids, such as fentanyl: 29.0 deaths per 100,000 people for men, 11.1 for women;

Heroin: 5.5 deaths per 100,000 people for men, 2.0 for women;

Psychostimulants, such as methamphetamine: 13.0 deaths per 100,000 people for men, 5.6 for women; and

Cocaine: 10.6 deaths per 100,000 people for men, 4.2 for women.

Higher overdose death rates for men were consistent across states, even when accounting for other demographic factors. The difference in overdose mortality between men and women was significantly more significant than in reported drug misuse between men and women. For example, men had a 2.8 greater rate of cocaine overdose mortality than women while having just a 1.9 greater rate of cocaine misuse.

“These data emphasize the importance of looking at the differences between men and women in a multi-layered way,” Eduardo R. Butelman, Ph.D., assistant professor of psychiatry at the Icahn School of Medicine at Mount Sinai and a lead author on the study, said in a news release. “Moving forward, it will be important for researchers to continue to investigate how biology, social factors, and behaviors intersect with sex and gender factors, and how all of these can impact addictive drug misuse and overdose deaths.”

The authors hypothesize that it is a combination of biological factors (e.g., men may have a greater vulnerability to the toxicity of drugs than women), behavioral factors (e.g., men may use these drugs in a riskier way than women), as well as other social- and gender-related factors.

The Loneliness Crisis

One possible factor is the lack of mitigating social connections. A 2019 study found that “females find same-sex social interactions to be more rewarding than males, and females are more sensitive to the rewarding actions of oxytocin than males.” As we reported on this blog, approximately one in five American men say they do not have a close friend. “Only 30 percent of men reported having a private conversation with a close friend when they divulged personal emotions in the past week,” wrote psychiatry professor Charles Hebert in a 2022 Newsweek article.

This comes at a cost. “Loneliness increases the risk of mental illness among men,” warned Hebert. “Persistent loneliness independently predicts risk of Alzheimer's disease. Additionally, psychiatric illnesses such as major depressive disorder often go unrecognized in men due to reluctance to discuss one's symptoms.”

Persistent social isolation, depression, anxiety, and trauma are major drivers of substance misuse and addiction. “Addiction is an illness of escape. Its goal is to obliterate, medicate, or ignore reality. It is an alternative to letting oneself feel hurt, betrayal, worry, and—most painful of all—loneliness,” Patrick Carnes wrote in Facing the Shadow. “Escaping reality for even the briefest time brings some relief. When escaping becomes habitual, we have a mental illness known as addiction.”

In a famous 2016 TED Talk, Johann Hari provocatively stated that the opposite of addiction is not sobriety but human connection. Surgeon General Vivek Murthy warned in May that “widespread loneliness in the US poses health risks as deadly as smoking up to 15 cigarettes daily. About half of US adults say they’ve experienced loneliness, Dr. Murthy said in an 81-page report.

Foundry Treatment Center Steamboat operates a specialized men’s treatment program for adult males experiencing substance use and co-occurring mental health disorders. This report resonates with Clinical Compliance Director Jasmine Aranda, LPC, LAC, LAT, TTS, ADS. Aranda, who has years f experience focusing on male clients and the issues they relate that have led to the development of dual-diagnosis conditions, sees evidence that loneliness and purposelessness may play fundamental roles in this crisis.

“Cultural and socioeconomic shifts affecting all people started well before the pandemic, but the pandemic seems to have worsened and accelerated the effects of these issues. We regularly hear clients who feel financially insecure, uncertain how long they can remain gainfully employed or hold on to housing. They fear mostly for the future of loved ones. Many men we treat feel less cohesion with family, friends, and neighbors. It can be very difficult for people, especially those in rural parts of the country, to make a living as they used to or to carry on family-owned businesses. Women, men, and adolescents are affected mentally, emotionally, and physically by these problems,” says Aranda.

“Among our male residential clients, who tend to have families and careers, today’s culture is challenging their long-standing narratives. Societal sentiment and economic realities are making it harder for men to be sole breadwinners and fulfill the role of protector. Purposelessness is a major problem for many men. Fathers can feel like they don’t understand how to navigate a rapidly changing world and lack the knowledge or skills to help their children navigate it. They may feel displaced and devalued because of increased economic disparity and the inability to earn a living that affords them a good quality of life despite working hard. Even the values of ruggedness or toughness and stoicism that were prized by previous generations are seemingly being questioned as our society becomes more open to discussing hardship and mental health disorders — which is a very good thing.”

Aranda suggests that increased rates of death by overdose correlate to increased rates of despair and perceived uncertainty.

“This program focuses heavily on the resolution of trauma and the ability of people to naturally self-regulate their autonomic nervous response to stress. Many of our clients live with a constant, debilitating rate of anxiety, hypervigilance, and panic that may, in part, be the response to increased uncertainty. We can help men by making it safe and comfortable for them to seek help, increasing awareness about the rise in uncertainty and anxiety, and helping them connect and feel valued. Doing these things could go a long way in reducing the perceived severity of the issues that drive them to misuse substances to feel normal or relieved.”