State-level excess drug overdose mortality by race/ethnicity in the U.S., 2020–2023: A population-scaling analysis during the COVID-19 pandemic

: The COVID-19 pandemic coincided with worsening U.S. drug overdose mortality and widening racial and ethnic disparities. We estimated race/ethnicity–specific state-level excess overdose deaths in 2020–2023 and assessed how the burden scales with population size. Using annual overdose deaths (2014–2023) for five racial/ethnic groups in 47 states and the District of Columbia, we fit a generalized growth model to 2014–2019 and defined excess deaths as observed counts above projected pre-pandemic expectations in 2020–2023. We assessed scaling by regressing log 10 excess and total deaths on log 10 2020 population and compared excess-death rates across groups. White populations had the largest absolute excess, peaking in 2021. Black populations had minimal excess in 2020 but rose sharply in 2021–2022, approaching White counts by 2023; Hispanic excesses were intermediate. Scaling was approximately proportional for White and Hispanic populations. For Black populations, total deaths showed sublinearly, and excess-death scaling was suggestive of sublinearity but not definitive. Rank tests indicated higher excess-death rates for Black populations than for White or Hispanic populations. These analyses highlight heterogeneous, inequitable overdose burdens in 2020–2023 and motivate equity-focused surveillance and prevention.