Recent Trends in Young Adult Mortality

2025-26 BUDGET Recent Trends in Young Adult Mortality LEGISLATIVE ANALYST’S OFFICE 2024 www.lao.ca.gov 1 AN LAO REPORT 2 LEGISLATIVE ANALYST’S OFFICE AN LAO REPORT Executive Summary California’s Age 15 to 44 Death Rate Still Much Higher Than Before Pandemic. In this report, we describe a worrisome trend: overall mortality among Californians between the ages of 15 and 44 is still much higher than it was before the COVID-19 pandemic. In 2023, 15-to-44-year-old Californians (to whom we refer as “young adults” in this report) died at a rate of 128 per 100,000 people, compared to just 99 per 100,000 in 2019—representing an increase of nearly 30 percent. State’s Age 15 to 44 Death Rate Lower Than Rest of Nation, but Has Grown Faster Recently. California has long had a lower age 15 to 44 mortality rate than the rest of the United States. As in California, young adult deaths in the rest of the nation grew rapidly in 2020 and 2021 and remain well above pre-pandemic levels. Notably, however, young adult mortality in California has not fallen as quickly from the 2021 peak as it has in the rest of the nation. Striking Demographic, Geographic, and Socioeconomic Disparities in Mortality Trends. Recent growth in age 15 to 44 mortality has been especially pronounced for men, Native American and Black Californians, and residents of rural northern counties and the state’s lowest-income zip codes. Trend Driven Largely by Drugs, Alcohol, and Motor Vehicle Crashes. Drug overdoses account for 60 percent of the recent growth in age 15 to 44 mortality. Alcohol-induced deaths and motor vehicle crashes each account for 10 percent. Firearm homicides, COVID-19, and other causes of death account for smaller portions of the mortality trend. Growth in Overdose Deaths Driven by Fentanyl. Age 15 to 44 drug overdose deaths were growing before the pandemic, but this growth accelerated substantially in early 2020. Since then, this growth has slowed but not reversed, so young adults are still dying from overdoses at a much higher rate than before the pandemic. One of the major factors driving this trend has been the growing presence of fentanyl—a synthetic opioid—in California’s illicit drug markets. In 2019 and 2020, growth in young adult overdose deaths was driven mainly by overdoses that involved synthetic opioids but not psychostimulants (such as methamphetamine). Since 2020, however, growth in these deaths has been driven mainly by overdoses involving both synthetic opioids and psychostimulants. Disruptions to substance use treatment also might have contributed to the early-pandemic growth in overdose deaths. Enrollment in medication-assisted treatment for opioid use disorder at treatment facilities was 42 percent lower in March 2020 than in March 2019. Growth in Alcohol Deaths Likely Driven by Group With Preexisting High Risk. As with drug overdose deaths, growth in alcohol-induced young adult deaths accelerated substantially in early 2020, and this death rate remains much higher than before the pandemic. A couple of indicators suggest that this growth likely has consisted largely of relapses or other disruptions that affected a particularly vulnerable population with long-standing alcohol use disorders. First, deaths from alcoholic liver disease grew quickly in 2020, but this disease generally develops only after several years or more of heavy drinking. Second, total statewide alcohol consumption changed only modestly in 2020. www.lao.ca.gov 3 AN LAO REPORT Extreme Speeding and Other Risky Driving Likely Contributing Significantly to Growth in Motor Vehicle Deaths. Age 15 to 44 motor vehicle deaths grew substantially in 2020 and remain elevated despite a persistent decline in the total amount of driving on California roads. California Highway Patrol citations for driving over 100 miles per hour nearly doubled between 2019 and 2020. In 2023, the number of such citations was still nearly 30 percent higher than in 2019, indicating a persistent increase in extreme speeding. Perhaps more people are speeding because they are not constrained by traffic. Consistent with this explanation, traffic congestion dropped sharply in early 2020 and remains well below pre-pandemic levels. When we examine the “primary collision factors” reported by law enforcement, however, the growth in young adult fatalities appears to be spread across many different types of traffic violations. Some of these violations have a plausible connection to speeding, but others do not—suggesting a broader change in risky driving behaviors. Despite this apparent growth in dangerous driving, the largest state and local law enforcement agencies are stopping fewer drivers for moving violations than they were before the pandemic. Explore Options in Key Policy Areas, but Also Consider Issue More Broadly. These mortality trends present major challenges for the Legislature to tackle through policies and programs related to drugs, alcohol, and traffic safety. A key purpose of this report, however, is to illustrate a broader picture than those we can see through specialized policy lenses. The Legislature also could look for opportunities to address young adult mortality through other areas of health policy and public safety policy. 4 LEGISLATIVE ANALYST’S OFFICE AN LAO REPORT INTRODUCTION In this report, we describe a worrisome trend: to several major areas of state and local public overall mortality among Californians (and Americans policy. That said, the report does not cover more generally) between the ages of 15 and 44 is specific responses that policymakers might still much higher than it was before the COVID-19 consider. We hope that this analysis will serve as pandemic. The purpose of this report is to provide a broad foundation for further discussions about information to help the Legislature and the public such responses. understand various aspects of this trend. While The first section of the report provides a this report includes a description of some factors broad overview of recent trends in age 15 to 44 that could be contributing to the problem, a mortality. The second section breaks out this comprehensive investigation of such factors is growth by underlying causes of death. Subsequent beyond our scope here. We hope that this report sections take a closer look at some of the major will prompt further research along those lines. causes of death and discuss some key issues for We bring this problem to the Legislature’s legislative consideration. and the public’s attention due to its relevance OVERVIEW OF RECENT TRENDS Overall Statewide Trend the mid-1990s through the first decade of the 2000s. After hitting an all-time low in 2010, young California’s Age 15 to 44 Death Rate Still adult mortality started growing. That change was Much Higher Than Before Pandemic. Over the worrisome in its own right, but in hindsight, the first couple years of the COVID-19 pandemic, growth rate was relatively modest. As shown in the state’s overall death rates (encompassing Figure 1 below, the growth in the initial years of the all causes of death) for adults of all age groups COVID-19 pandemic far outpaced the prior trend. grew substantially. By 2023, death rates for most age groups had dropped back to pre-pandemic levels. Figure 1 As shown in Figure 1, however, the Age 15 to 44 Death Rate Still 15-to-44-year-old age group (to whom we refer as “young adults” in Much Higher Than Before Pandemic this report) is an exception. Although Annual Deaths Per 100,000 Californians Age 15 to 44, All Causes the death rate for these Californians is down from its 2021 peak, it remains 152 much higher than its pre-pandemic level. In 2023, California’s young 128 adults died at a rate of 128 per 100,000 people, compared to just 86 99 99 per 100,000 in 2019—representing an increase of nearly 30 percent. To put these death rates into perspective, we briefly describe the state’s longer-term young adult mortality trends. The age 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 15 to 44 death rate declined from Source: National Vital Statistics System, accessed through Centers for Disease Control and Prevention WONDER online database. www.lao.ca.gov 5 AN LAO REPORT Even after a couple of years of substantial declines, Trends by Gender and Race California’s young adult death rate in 2023 was Deaths Have Grown Faster for Young Men around the same level as in 1996. Than for Young Women. Figure 3 displays recent State’s Age 15 to 44 Death Rate Lower Than changes in age 15 to 44 mortality rates by gender. Rest of Nation, but Has Grown Faster Recently. California has had a substantially lower young adult death rate than Figure 2 the rest of the United States for at California’s Age 15 to 44 Death Rate Lower least a quarter-century. From 2016 through the first couple years of the Than Rest of Nation but Has Grown Faster Recently pandemic, this difference in death Annual Deaths Per 100,000 People Age 15 to 44, All Causes rates was even bigger than it had 180 been historically. 160 Figure 2 compares age 15 to 44 140 mortality trends between California 120 and the rest of the nation from 2019 to 2023. These trends have 100 been similar in some respects. 80 For example, both rates grew fast 60 in 2020 and 2021. Despite recent 40 declines, both remain well above 20 pre-pandemic levels. Notably, 2019 2023 2019 2023 however, young adult mortality California Rest of USA in California has not fallen as Source: National Vital Statistics System, accessed through Centers for Disease Control and Prevention quickly from the 2021 peak as it WONDER online database. has in the rest of the nation. As a result, the difference between California’s death rate and the rest Figure 3 of the nation’s has narrowed. The current size of this gap is similar Death Rate Has Grown Faster for to what it was from the late 1990s Young Men Than for Young Women through 2015. Annual Deaths Per 100,000 Californians Age 15 to 44, All Causes From this comparison, we see that elevated young adult 200 mortality is not a problem unique 180 to California. As we discuss 160 later in this report, however, a 140 closer look at this trend suggests 120 that California’s state and local 100 governments could play an 80 important role in addressing the 60 problem. Before we turn to that 40 part of the discussion, we first 20 examine differences in mortality trends across genders, races, and 2019 2023 2019 2023 geographic areas. Women Men Source: National Vital Statistics System, accessed through Centers for Disease Control and Prevention WONDER online database. 6 LEGISLATIVE ANALYST’S OFFICE AN LAO REPORT From 2019 to 2023, the annual death rate for young Trends by County men grew by 44 deaths per 100,000 people, while Young Adult Deaths Have Grown Fastest the annual death rate for young women grew by 13 in North Coast, San Francisco, and Parts of deaths per 100,000. As shown in the figure, this Inland California. The map portion of Figure 6 difference in growth exacerbated an existing large (on the next page) groups California counties by gender gap. The death rate for 15-to-44-year-old the recent growth in their young adult death rates. men is now 140 percent higher than the rate for women in that age range. Figure 4 Growth in Young Adult Growth in Young Women’s Death Rates Deaths Disparate Among Disparate Among Racial/Ethnic Groups Racial/Ethnic Groups. Figure 4 Annual Deaths Per 100,000 California Women Age 15-44, All Causes displays recent changes in young women’s mortality rates by race, while Figure 5 displays recent 400 2018 and 2019 changes by race for young men. 350 2022 and 2023 Taken together, the two figures 300 illustrate striking racial differences 250 in mortality trends both within each gender and overall. Black and 200 Native American young men’s death 150 rates have grown by more than 100 100 annual deaths per 100,000 50 people—faster than any other race-gender groups. Although Asian Latina/HispanicMultiracial White Pacific Islander Black Native American women’s overall age 15 to 44 death Source: National Vital Statistics System, accessed through Centers for Disease Control and Prevention rate has grown much more slowly WONDER online database. than men’s, death rates for some groups of young women have grown very fast. In particular, age Figure 5 15 to 44 mortality has grown faster Growth in Young Men’s Death Rates for Native American women than Disparate Among Racial/Ethnic Groups for most groups of men, let alone Annual Deaths Per 100,000 California Men Age 15-44, All Causes other groups of women. These racial differences in mortality trends largely have 400 2018 and 2019 mirrored pre-existing disparities in 350 2022 and 2023 death rates. One notable exception 300 is the gap between white and 250 Latino/Hispanic men. Before the 200 pandemic, Latino/Hispanic young 150 men were dying at substantially 100 lower rates than white men, but their death rate has grown faster in 50 recent years. Asian MultiracialLatino/Hispanic White Pacific Islander Black Native American Source: National Vital Statistics System, acessed through Centers for Disease Control and Prevention WONDER online database. www.lao.ca.gov 7 AN LAO REPORT Figure 6 Rural Northern Counties Have Highest Young Adult Death Rates Growth in Age 15 to 44 Death Rates Annual Deaths Per 100,000 Varies Across Counties People Age 15 to 44, 2022 and Counties 2023 Change in Annual Age 15 to 44 Del Norte, Siskiyou, Trinity 281 Mortality Rate From 2018 and 2019 Mendocino 230 to 2022 and 2023 Deaths Per 100,000 People Humboldt 219 Lassen, Shasta 218 Over 45 Colusa, Glenn, Lake, Tehama 217 35 to 45 Kern 196 25 to 35 Inyo, Mariposa, Mono, Tuolumne 187 Less than 25 Sutter 182 Data Not Available Yuba 179 Stanislaus 177 San Bernardino 170 Solano 164 San Joaquin 162 Amador, Calaveras, Fresno 160 Merced 157 Butte, Tulare 156 El Dorado, Sacramento 155 Nevada 152 Riverside 145 Madera 144 Kings 139 Sources: National Vital Statistics System, accessed through Centers for Disease Control and Prevention WONDER online database; American Community Survey. Imperial 135 Los Angeles 131 Santa Cruz 127 Among these, the fastest growth—increases of Sonoma 126 more than 60 annual deaths per 100,000 people— Contra Costa 124 has occurred in five counties in the northwestern San Luis Obispo 123 corner of the state: Del Norte, Siskiyou, Humboldt, Ventura 122 San Francisco 120 Trinity, and Mendocino. Death rates in San Santa Barbara 119 Francisco and some inland parts of the state have Monterey 115 grown by 45 to 50 annual deaths per 100,000. Alameda 111 Placer 109 Most other parts of the state have experienced San Diego 108 substantial but less extreme growth. Most of the Orange 107 counties with relatively modest growth—less than Marin 94 25 annual deaths per 100,000—are concentrated in Napa 87 Yolo 82 the Sierra Nevada region and parts of the Bay Area. San Mateo, Santa Clara, San 79 Rural Northern Counties Have Highest Young Benito Adult Death Rates. The table portion of Figure 6 Sources: National Vital Statistics System, accessed through Centers for Disease Control and Prevention WONDER online database; American Community lists the most recent age 15 to 44 mortality rate for Survey each county. The counties with the highest young adult death rates are all in the rural northern part Death Rates by Local Income Level of the state. This group includes not just the five counties where deaths have grown fastest recently, Highest Young Adult Death Rates but the inland northern counties as well. At the Concentrated in Low-Income Zip Codes. other end of the spectrum, the counties with the The demographic and geographic breakdowns lowest young adult death rates are concentrated discussed above come from publicly available vital in or near the Bay Area. Overall, these geographic statistics. Unfortunately, this data source does not gaps, though quite substantial, generally are give us much other socioeconomic information smaller than the racial gaps noted above. about people who die. By combining multiple 8 LEGISLATIVE ANALYST’S OFFICE AN LAO REPORT sources of data, however, we can learn something about the Figure 7 distribution of young adult deaths Highest Age 25 to 44 Death Rates across local communities that face Concentrated in Low-Income Zip Codes different economic conditions. Number of Zip Codes For this exercise, our key measure of local economic Statewide Median Household Income 80 conditions is the median household income in a zip code. In Figure 7, the green bars show the distribution 60 of median household incomes State's 500 Largest Zip Codes for the state’s 500 largest zip Zip Codes With Highest codes. The purple bars show the Age 25 to 44 Mortality Rates in 2022 40 distribution of median household incomes for the zip codes with the highest age 25 to 44 death rates. 20 As shown in the figure, most of the highest-mortality zip codes are among the lowest-income zip codes in the state. 50,000 100,000 150,000 200,000 $250,000 Median Household Income in Zip Code in 2022 Sources: American Community Survey and California Department of Public Health, Zip Code Death Profiles. WHICH CAUSES OF DEATH ARE DRIVING THESE TRENDS? Having documented California’s persistent, unequal growth in young Figure 8 adult deaths, we now explore potential explanations for this trend. Change in Deaths by Underlying Cause, 2019 to 2023 As a starting point, we break down Share of 2019 to 2023 Overall Increase in the recent increase in mortality by the Deaths Among Californians Age 15 to 44 underlying causes of death identified on death certificates. 70% Of course, this discussion of 60 pandemic-era causes of death must 50 start with COVID-19 itself. The virus 40 killed many young adults in 2020 and 2021. Looking back at Figure 1, 30 the overall age 15 to 44 death rate 20 grew quickly over that period, and 10 COVID-19 deaths accounted for a Drug Motor Vehicle Alcoholic Mental and Firearm COVID-19 large share of that growth. By 2023, Overdoses Crashes Liver Disease Behavioral Homicides however, deaths from the virus Disorders Due to Alcohol Use had become much less common, Source: National Vital Statistics System, accessed through Centers for Disease Control and Prevention especially for this age group. WONDER online database. As shown in Figure 8, COVID-19 deaths account for just 3 percent www.lao.ca.gov 9 AN LAO REPORT of the growth in young adult mortality from 2019 and gender. Age 15 to 44 motor vehicle crash to 2023. For the rest of this report, we turn our deaths have grown four times as much for men as attention to the other underlying causes of death for women, while young men’s alcohol deaths have shown in the figure. grown twice as much as young women’s. For motor Drug Overdoses Account for 60 Percent vehicle deaths, the fastest-widening racial disparity of Growth in Age 15 to 44 Deaths. The most has been the Latino-white gap, as this type of death striking feature of Figure 8 is the large share of has grown 4.4 times as fast for Latino young adults. growth driven by drug overdoses. By now, the For alcohol deaths, the fastest-widening racial Legislature and much of the public are well aware disparity has been the Black-Asian gap, as this that California and the rest of the nation are facing type of death has grown 4.4 times as fast for Black a drug overdose crisis. Even so, Figures 1 and 8 young adults. together paint a sobering picture: the overall rate Notable Trend in Firearm Deaths. After the of young adult mortality is much higher than it was causes of death discussed above, the next-biggest in 2019—indeed, higher than at any point from contributor to growth in age 15 to 44 deaths has 1997 through 2019—and overdose deaths are been firearm homicides. This is not a large part the main reason for this. Drug overdoses also are of the overall trend—like the COVID-19 virus, it the main driver of disparities in the race-specific accounts for 3 percent of the growth. That said, it and gender-specific trends described in the is part of a notable pattern. As shown in Figure 9, previous section. firearm homicides and firearm suicides both Motor Vehicle Crashes and Alcohol-Induced increased between 2019 and 2023. In contrast, over Deaths Each Account for 10 Percent of the same period, non-firearm homicides were flat, Growth. Although drug overdoses are the and non-firearm suicides declined. biggest contributor to recent growth in age 15 to Different Types of “Deaths of Despair” 44 mortality, they are far from the only one. Following Different Trends. Nearly a decade As shown in Figure 8, motor vehicle crashes and ago, a couple of researchers coined the term alcohol-induced deaths also account for substantial “deaths of despair,” a category that combines drug shares of the growth. Compared to the drug overdoses, alcohol-induced deaths, and suicides. overdose crisis, these problems seem to be less well known among Figure 9 broad policy audiences. As shown in the figure, the Firearm Deaths Have Increased, but growth in alcohol-induced deaths Other Intentional Deaths Have Not is split evenly between two Annual Deaths Per 100,000 Californians Age 15 to 44 categories. The first category is alcoholic liver disease, a condition 9 that generally results from 2019 8 heavy drinking over many years. 2023 7 The second category is “mental/ 6 behavioral disorders due to alcohol 5 use,” a broad term covering various 4 types of deaths that can result from chronic alcohol use disorders 3 or shorter-term episodes of 2 binge drinking. 1 Although the relative Firearm Homicides Firearm Suicides Non-Firearm Non-Firearm contributions of motor vehicle and Homicides Suicides alcohol deaths are similar overall, Source: National Vital Statistics System, accessed through Centers for Disease Control and Prevention this varies substantially by race WONDER online database. 10 LEGISLATIVE ANALYST’S OFFICE AN LAO REPORT This term evokes various forms of social, economic, In light of the flat suicide trend and the large role and emotional stress that can lead to such deaths. played by motor vehicle deaths, the applicability of As discussed above, drug and alcohol deaths the “deaths of despair” concept is unclear. Instead, both have grown very fast among young adults, this trend might be driven by pandemic-era social and this trend has been especially pronounced and policy changes that earlier research did not for socioeconomically disadvantaged groups. anticipate. Research that tries to disentangle the As shown in Figure 9, however, overall suicides in effects of these myriad changes would be quite this age group have not grown, as the growth in valuable. In the next couple of sections of this firearm suicides has been fully offset by a decline in report, we take some initial steps to shed light on non-firearm suicides. the nature of these deaths. A CLOSER LOOK AT SUBSTANCE USE DEATHS In this section, we examine trends in young adult As a result, the number of deaths remains highly drug- and alcohol-related deaths. We also explore elevated, roughly double the 2019 level. some potential explanations for these trends and Fentanyl Overdoses highlight some aspects of the trends that might be of particular interest to policymakers. Fentanyl is a synthetic opioid. Compared to other commonly used illicit opioids like heroin, fentanyl Trend in Young Adult is more potent and also is cheaper to produce Drug Overdose Deaths and distribute. Shortly Before Pandemic, Young Adult Drug Growth in Drug-Induced Deaths Driven Overdose Deaths Were Growing Substantially. by Fentanyl Overdoses. The top left panel of Figure 10 displays total quarterly drug overdose Figure 11 on the next page breaks down the deaths among Californians age 15 to 44 over the quarterly trend in age 15 to 44 overdose deaths last six years. These deaths were growing at a fast into overdoses involving fentanyl (often along with rate even before the COVID-19 other drugs) and overdoses not involving fentanyl. pandemic. On average, they grew 5 percent per quarter from early Figure 10 2018 to late 2019. Young Adult Drug Overdose Deaths Growth Accelerated in Early Grew Substantially in 2020 2020. As shown in the figure, Quarterly Total Drug Overdose Deaths Among Californians Age 15 to 44 the upward trend in young adult overdose deaths accelerated 1,600 substantially in the first quarter of 2020. In early-to-mid-2020, 1,400 these deaths grew at an average 1,200 quarterly rate of 21 percent. 1,000 Overdose Deaths Still Much 800 Higher Than Before Pandemic. 600 Since the third quarter of 2020, growth in young adult overdose 400 deaths has slowed but not 200 reversed, with an average quarterly growth rate around 0.8 percent. 2018Q1 2018Q3 2019Q1 2019Q3 2020Q1 2020Q3 2021Q1 2021Q3 2022Q1 2022Q3 2023Q1 2023Q3 Source: National Vital Statistics System, accessed through Centers for Disease Control and Prevention WONDER online database. www.lao.ca.gov 11 AN LAO REPORT Figure 11 Growth in Young Adult Overdose Deaths Driven by Fentanyl Quarterly Overdose Deaths Among Californians Age 15 to 44 Drug Samples Submitted to Laboratories From Law Enforcement Seizures in California 1,200 20,000 18,000 1,000 16,000 Heroin 800 14,000 Fentanyl 12,000 600 Non-Fentanyl 10,000 400 8,000 6,000 200 4,000 Fentanyl 2,000 2018 Q1 2019 Q1 2020 Q1 2021 Q1 2022 Q1 2023 Q1 2018 2019 2020 2021 2022 Share of Opioid Overdose Deaths, Age 15 to 44 Quarterly Overdose Deaths Among Californians Age 15 to 44 100% 700 90 Synthetic Opioids Without Psychostimulants 80 Fentanyl 600 70 500 60 50 400 40 300 30 20 Heroin 200 Synthetic Opioids With Psychostimulants 10 100 2018 Q1 2019 Q1 2020 Q1 2021 Q1 2022 Q1 2023 Q1 2018 Q3 2019 Q3 2020 Q3 2021 Q3 2022 Q3 2023 Q3 Sources: California Department of Public Health, Substance and Addiction Prevention Branch, California Overdose Surveillance Dashboard (top left and bottom left); U.S. Drug Enforcement Administration, Diversion Control Division, National Forensic Laboratory Information System (top right); and National Vital Statistics System, Accessed through Centers for Disease Control and Prevention WONDER Online Database (lower right). Non-fentanyl overdose deaths did not change panel of Figure 11. Before the COVID-19 pandemic, much from 2018 to 2021, and they have been California law enforcement seized heroin much declining since 2021. In contrast, fentanyl overdose more often than they seized fentanyl. Over time, deaths grew fast from 2019 through 2021 and have however, seizures of fentanyl grew and seizures of remained elevated since then. heroin declined. By 2022, the two drugs’ relative Fentanyl, Not Heroin, Now Dominates positions had reversed, and seizures of fentanyl California’s Illicit Opioid Markets. Our review far exceeded seizures of heroin. This is especially of research and discussions with experts have striking because fentanyl’s potency makes an indicated a general consensus that fentanyl has equivalent amount much easier to conceal. taken over California’s illicit opioid markets in recent Our second indirect approach relies on mortality years, displacing heroin and other drugs. Measuring data—in particular, the shares of age 15 to 44 illegal activity, however, is very difficult, so we use a opioid overdose deaths involving heroin and couple of indirect approaches to try to gauge how fentanyl respectively. The results appear in the fentanyl’s market presence has evolved over time. bottom left panel of Figure 11. In 2018, slightly less First, like other researchers, we look at the than half of young adult opioid overdose deaths number of samples of heroin and fentanyl involved fentanyl, and one-third involved heroin. sent to testing labs after being seized by law Now, 95 percent of those deaths involve fentanyl, enforcement. The results appear in the top right and around 3 percent involve heroin. 12 LEGISLATIVE ANALYST’S OFFICE AN LAO REPORT Recent Growth Largely Driven by Overdoses that could enable us to evaluate these possibilities. Involving Both Synthetic Opioids and In the next two parts of this section, we explore Psychostimulants. Due to fentanyl’s low cost, high potential explanations that are more quantifiable: potency, and ubiquity in drug markets, people often (1) participation in medication-assisted treatment intentionally or unintentionally use it along with and (2) homelessness. other drugs. As a result, many fentanyl overdose Medication-Assisted Treatment for deaths involve other drugs as well. One of the most common pairings consists of fentanyl and Opioid Use Disorders a psychostimulant, typically methamphetamine. Medication-Assisted Treatment. In the As shown in the bottom right panel of Figure 11, context of opioids, the term “medication-assisted this pairing of drugs has played a large and growing treatment” refers to ongoing treatment for opioid role in the fentanyl overdose crisis. In 2019 and use disorder with buprenorphine, methadone, or 2020, growth in young adult overdose deaths was naltrexone. Naltrexone blocks the effects of opioids, driven mainly by overdoses that involved synthetic whereas buprenorphine and methadone reduce opioids (a category dominated by fentanyl) but cravings and withdrawal symptoms. Only federally not psychostimulants. Since 2020, however, registered treatment programs may dispense growth in young adult overdose deaths has methadone. The other two medications are been driven mainly by overdoses involving both available in a wider range of clinical settings. synthetic opioids and psychostimulants. Since the Participation in Facility-Based Treatment second half of 2020, deaths involving synthetic Dropped Substantially in Early 2020. opioids without psychostimulants have grown by Figure 12 displays statewide enrollment in 0.3 percent per quarter, while deaths involving both medication-assisted treatment from a survey of types of drugs have grown by more than 5 percent treatment facilities, which we discuss in more per quarter. detail in the Appendix. As shown in the figure, Some Potential Explanations Are Difficult to enrollment in these programs was 42 percent Quantify. As described above, fentanyl overdose lower in March 2020 than in March 2019. These deaths among young adults grew very fast in enrollment numbers rebounded by March 2021 but 2020 and have remained elevated since then. still remain noticeably below pre-pandemic levels. Some plausible explanations for this mortality trend are very hard Figure 12 to verify directly. For example, using drugs alone is a major risk Medication-Assisted Treatment at factor for overdose death, as other Specialized Facilities Dropped Substantially in March 2020 people are not well-positioned Clients Receiving Medication-Assisted to respond quickly if the user Opioid Therapy at Substance Use Treatment Facilities overdoses. Although many observers believe that solitary 60,000 drug use grew substantially 50,000 during the early phases of the COVID-19 pandemic, we have 40,000 not found a way to assess this 30,000 quantitatively. Similarly, we can speculate that other key risk 20,000 factors like anxiety and social 10,000 isolation might have contributed to the early-pandemic growth in March 29, 2019 March 31, 2020 March 31, 2021 March 31, 2022 overdose deaths, but we have not found any systematic evidence Source: California state profiles from 2019 and 2020 National Survey of Substance Abuse Treatment Services and 2021 and 2022 National Substance Use and Mental Health Services Survey. www.lao.ca.gov 13 AN LAO REPORT This pattern suggests that early-pandemic changes light on the relationship between homelessness and in access to medication-assisted treatment might overall drug overdose mortality. have contributed to the rapid growth in overdose Much of the Growth in Los Angeles County deaths in 2020. On the other hand, the rebound in Overdose Deaths Occurred Among People enrollment, while incomplete, suggests that access Experiencing Homelessness. As a first step, to this type of treatment is less likely to explain the we look at the role of homelessness in overall persistently high level of overdose deaths. drug overdose mortality trends in Los Angeles Buprenorphine Prescriptions Likely Did Not County. From 2019 to 2022, Los Angeles County Offset Decline in Facility-Based Treatment. drug overdose deaths grew by 97 percent. Drug A substantial amount of medication-assisted overdose deaths among people experiencing treatment—particularly treatment with homelessness account for 42 percent of this buprenorphine—occurs in other clinical settings growth. (We cannot narrow the homeless mortality besides the treatment facilities described in data to the 15 to 44 age range, so these numbers Figure 12. We examine buprenorphine prescription are not age-specific.) People experiencing trends in these settings using two different data homelessness face a particularly high risk of sources, which we discuss in more detail in the overdose death, and they are numerous enough Appendix. Although the two sources provide to contribute very substantially to the overall conflicting information about many aspects of countywide trend. this trend, they both indicate that buprenorphine In Los Angeles County, Homeless Overdose prescriptions did not rise in 2020. This means Death Rate Has Grown Much Faster Than that the early-pandemic decline in facility-based Homeless Population. Among people treatment likely was not offset by rising experiencing homelessness in Los Angeles buprenorphine use in other settings. County, the total number of overdose deaths grew from 341 in 2019 to 826 in 2022—an increase of Overdose Deaths Among People 142 percent. To better understand this growth, Experiencing Homelessness we break it into two pieces: (1) growth in the size In recent years, the state’s growing of the homeless population and (2) increasing risk homelessness problem has been a highly salient of overdose mortality among people experiencing issue for the Legislature and for the public more homelessness. Over this period, the estimated broadly. Many people experiencing homelessness number of people experiencing homelessness struggle with substance use disorders, so one in Los Angeles County grew by 17 percent, but might wonder about potential relationships between their per capita overdose death rate doubled. homelessness and the rise in young adult overdose These numbers suggest that most of the county’s deaths. We use data from Los Angeles County to growth in overdose deaths has not occurred simply explore this issue below. because more people are living on the streets. Mortality Estimates for People Experiencing Rather, other factors that affect the risk of overdose Homelessness Available for Some Counties, but death both for housed and unhoused people—such Not Statewide. Neither the national vital statistics as the pervasive presence of fentanyl—appear to be system nor administrative data from the state more important. track homelessness mortality systematically, so Alcohol Trends we cannot provide a statewide summary of deaths among young adults experiencing homelessness. Continuing the discussion of substance use, we That said, researchers who examine death now turn our attention to alcohol-induced deaths. certificates closely can reasonably infer whether the Compared to drug overdoses, these deaths have decedent likely was experiencing homelessness. played a smaller but nevertheless significant role in Some California counties have investigated this recent age 15 to 44 mortality trends. issue thoroughly enough to publish aggregate Before Pandemic, Alcohol-Induced Young statistics on deaths among people experiencing Adult Deaths Were Growing. As shown in homelessness. As described below, Los Angeles Figure 13, alcohol was killing a growing number County has done so in a way that helps shed some of California young adults even before the 14 LEGISLATIVE ANALYST’S OFFICE AN LAO REPORT COVID-19 pandemic. On average, these deaths is access to treatment for alcohol use disorders. grew 2 percent per quarter in 2018 and 2019. Earlier in this report, we used data from federal Growth Accelerated in 2020. The growth rate surveys of treatment facilities to look at trends in in alcohol-induced young adult deaths accelerated treatment for opioid use. Now we use the same substantially in early 2020 and continued to grow data source to look at trends in treatment for quickly throughout that year. The quarterly growth alcohol use. The results appear in Figure 14. rate in 2020 was around 9 percent. Enrollment in treatment for combined drug and alcohol use has followed a pattern reminiscent of Alcohol-Induced Deaths Still Much the opioid treatment trend: a large drop in 2020 Higher Than Before Pandemic. Since 2020, followed by a partial rebound in subsequent years. alcohol-induced young adult deaths have fluctuated from one quarter to the next, but have remained elevated. As a result, the Figure 13 number of such deaths in 2023 was 53 percent higher than in 2019. Alcohol-Induced Young Adult Trend in Alcoholic Liver Disease Deaths Grew Substantially in 2020 Likely Driven by Group With Quarterly Total Alcohol-Induced Deaths Among Californians Age 15 to 44 Preexisting High Risk. As discussed earlier in this report, alcoholic liver 450 disease and mental/behavioral 400 disorders due to alcohol use each 350 account for roughly equal parts of 300 the growth in alcohol-induced young 250 adult deaths. Figure 13 clearly shows 200 the growth rate in these deaths 150 accelerating abruptly in early 2020. 100 Notably, however, people generally 50 do not develop alcoholic liver disease 2018Q1 2018Q3 2019Q1 2019Q3 2020Q1 2020Q3 2021Q1 2021Q3 2022Q1 2022Q3 2023Q1 2023Q3 until they have been drinking heavily over the course of several years or Source: National Vital Statistics System, accessed through Centers for Disease Control and Prevention WONDER online database. more. As such, this portion of the mortality trend likely was not related directly to broad changes in alcohol Figure 14 consumption across the general Treatment for Combined Drug/Alcohol Use Dropped population. Instead, we suspect in March 2020, but Treatment Only for Alcohol Use Did Not that it consisted of relapses or other Clients Enrolled in Treatment at Substance Use Treatment Facilities disruptions that affected a particularly vulnerable population who already 35,000 had serious liver problems going into 30,000 the pandemic. To get to this point Drugs and Alcohol by early adulthood, these individuals 25,000 must have started drinking heavily 20,000 when they were relatively young. 15,000 Treatment for Combined Drug/ 10,000 Alcohol Use Dropped in Early Alcohol Only 5,000 2020, but Treatment Only for Alcohol Use Did Not. Among March 29, March 31, March 31, March 31, potential explanations for the alcohol 2019 2020 2021 2022 mortality trend, one that could be Source: California state profiles from 2019 and 2020 National Survey of Substance Abuse Treatment especially relevant for this group Services and 2021 and 2022 National Substance Use and Mental Health Services Survey. www.lao.ca.gov 15 AN LAO REPORT Enrollment in treatment only for Figure 15 alcohol use, however, has followed a very different trend. The number Alcohol Consumption Shifting of patients enrolled in this type of From Beer and Wine to Distilled Spirits treatment held steady from 2019 to Annual Drinks Sold in California (In Billions) 2020, then grew substantially from 2020 to 2021. 8 Beer Overall Alcohol Consumption 7 Did Not Change Much in 2020. 6 Distilled Spirits As discussed earlier in this 5 section, we would not necessarily 4 expect the rapid 2020 growth Wine 3 in alcohol-induced deaths to 2 be related to broad changes in 1 aggregate statewide alcohol 2018 2019 2020 2021 2022 2023 consumption. Indeed, as shown in Figure 15, overall alcohol Note: Drink estimates are based on total alcoholic beverage volume, assuming that a drink consists of 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of distilled spirits. consumption (through all channels, Source: California Department of Tax and Fee Administration. including stores and bars/ restaurants) changed only modestly to be shifting away from beer and wine towards in 2020. Sales of beer and distilled spirits rose a distilled spirits. Distilled spirits consumption bit higher than their 2019 levels, while wine sales has risen consistently every year, with 2023 dropped a bit. consumption exceeding 2018 consumption by Over Time, Alcohol Consumption Shifting 30 percent. Beer and wine consumption were From Beer and Wine to Distilled Spirits. Although roughly flat from 2018 to 2022, but both declined we see no indication that aggregate alcohol substantially in 2023: beer by nearly 10 percent and consumption contributed to the early-pandemic wine by nearly 30 percent. These striking trends are mortality trend, Figure 15 does show a noteworthy worth monitoring as the state considers potential trend. Over time, alcohol consumption appears changes to its alcohol policies. A CLOSER LOOK AT MOTOR VEHICLE DEATHS In this section, we discuss the remaining cause Since then, they have been declining gradually but of death that has contributed substantially to the remain in the range of 600 to 700 per quarter, far age 15 to 44 mortality trend: motor vehicle crashes. above the pre-pandemic level. Deaths Increased Despite Substantial Trend in Young Adult Decline in Driving. Strikingly, the rapid growth in Motor Vehicle Deaths motor vehicle deaths occurred shortly after a rapid Age 15 to 44 Deaths in Motor Vehicle drop in the total amount of driving. As shown in Crashes Increased in 2020. Figure 16 displays Figure 17, vehicle miles traveled (VMT) on California total quarterly motor vehicle crash deaths among roads dropped 18 percent in 2020 compared to Californians age 15 to 44 over the last six years. 2019. Although road travel has rebounded a bit From 2018 through the first half of 2020, the trend since 2020, it remains well below pre-pandemic was roughly flat around 500 deaths per quarter. levels. In 2023, statewide total VMT were still These deaths jumped to 673 in the third quarter 10 percent lower than in 2019. (Age-specific VMT of 2020, then to 723 in the fourth quarter of 2020. are not available.) 16 LEGISLATIVE ANALYST’S OFFICE AN LAO REPORT coinciding with the initial drop Figure 16 in driving—and peaked at 1.7 in the fourth quarter of 2020. Young Adult Deaths in This rate has been roughly flat Motor Vehicle Crashes Increased in 2020 around 1.5 since 2021. (This Quarterly Motor Vehicle Crash Deaths Among Californians Age 15 to 44 measure looks at deaths across all ages because, as noted 800 above, age-specific VMT are 700 not available.) 600 Growth Roughly Evenly Split 500 Between State Highways and 400 Local Roads. Many transportation policies and programs make a 300 major distinction between the 200 state highway system and local 100 roads. Using data from the Fatality Analysis Reporting System, 2018 Q1 2018 Q3 2019 Q1 2019 Q3 2020 Q1 2020 Q3 2021 Q1 2021 Q3 2022 Q1 2022 Q3 2023 Q1 2023 Q3 we estimate that 54 percent Source: National Vital Statistics System, accessed through Centers for Disease Control and Prevention WONDER online database. of California’s pandemic-era growth in age 15 to 44 motor vehicle deaths has occurred on Figure 17 the state highway system. The Vehicle Miles Traveled Dropped Abruptly in 2020, other 46 percent of the growth has occurred on local roads. This Remain Below Pre-Pandemic Level nearly even split indicates that Estimated Quarterly Vehicle Miles Traveled in California, Millions the mortality trend is a substantial concern for both systems. 120,000 100,000 Trends by Mode of Transport 80,000 Growth in Deaths Spread 60,000 Across Several Modes of Transport. In Figure 19 on 40,000 the next page, we break down 20,000 California’s pandemic-era growth in age 15 to 44 motor vehicle deaths 2018 Q1 2018 Q3 2019 Q1 2019 Q3 2020 Q1 2020 Q3 2021 Q1 2021 Q3 2022 Q1 2022 Q3 2023 Q1 2023 Q3 by the mode of transport of the person who died. Motor vehicle Source: Monthly Traffic Volume Trends published by Federal Highway Administration, Office of Highway Policy Information. occupants (except motorcyclists) account for 55 percent of this Per-Mile Death Rate Increased in 2020 and growth. Motorcyclists, pedestrians, Remains Elevated. An increase in deaths and a and pedal cyclists account for 19 percent, drop in driving means the per-mile death rate has 23 percent, and 3 percent respectively. increased significantly, as shown in Figure 18 on Growth in Motorist Deaths and Growth the next page. From early 2018 through late 2019, in Pedestrian Deaths Have Occurred Under crash deaths per 100 million VMT were roughly flat Different Light Conditions. Visibility is a key around 1.2. The death rate per 100 million VMT issue in transportation safety, especially in started growing fast in the first quarter of 2020— relation to walking and biking. For this reason, we www.lao.ca.gov 17 AN LAO REPORT further examine mode-specific Figure 18 mortality trends under various light conditions. The results appear Per-Mile Death Rate Increased in 2020 and Remains Elevated in Figure 20. Overall, nighttime Motor Vehicle Deaths Per 100 Million Vehicle Miles Traveled, All Ages crashes—including both lit and unlit roadways—account for 1.8 nearly 60 percent of the state’s pandemic-era growth in young 1.6 adult motor vehicle deaths. 1.4 Crashes under the poorest 1.2 light conditions account for a 1.0 particularly large share of the 0.8 growth in pedestrian deaths. 0.6 Specifically, 53 percent of the 0.4 growth in young adult pedestrian 0.2 deaths has occurred under dark skies without street lighting. In 2018 Q1 2018 Q3 2019 Q1 2019 Q3 2020 Q1 2020 Q3 2021 Q1 2021 Q3 2022 Q1 2022 Q3 2023 Q1 2023 Q3 contrast, crashes under these conditions account for just Sources: Deaths from National Vital Statistics System, accessed through Centers for Disease Control and Prevention WONDER online database. Vehicle miles traveled from monthly Traffic Volume Trends published by Federal Highway 20 percent of the growth in young Administration, Office of Highway Policy Information. adult motorist deaths. Note: These death rates are higher than some other commonly referenced numbers because motor vehicle crash death counts are higher in Vital Statistics than in the Fatality Analysis Reporting System or the Statewide Integrated Traffic Records System. This might be due, in part, to a broader definition of crash deaths. Has Driving Behavior Changed? Figure 19 Next, we explore some potential explanations for California’s Growth in Age 15 to 44 Motor Vehicle Deaths pandemic-era growth in age 15 to Spread Across Several Modes of Transport 44 motor vehicle deaths. In general, Share of 2019 to 2022 Increase in California Motor Vehicle Accident traffic safety depends on vehicle Deaths, Age 15 to 44 characteristics, the design and maintenance of the road system, 60% driving behavior, and various other 50 factors. Looking back at Figures 16 and 18, however, the trends we 40 are trying to explain are not gradual 30 changes. We are looking for factors that can account for rapid growth 20 in motor vehicle fatalities over the 10 course of several months to a year. As such, this section explores Motor Vehicle Occupant Pedestrian Motorcycle Rider Pedal Cyclist potential explanations related to (Except Motorcycles) various aspects of driver behavior. Source: Fatality Analysis Reporting System. California Highway Patrol (CHP) Citations for Extreme issued by CHP for driving over 100 miles per Speeding Grew During hour nearly doubled between 2019 and 2020. Pandemic. Driving speed is a major risk factor CHP citations for driving over 100 miles per hour for motor vehicle fatalities. We have seen some declined a bit after 2020, but the number of such indications that extreme speeding has grown citations was still 29 percent higher in 2023 than substantially. As shown in Figure 21, citations in 2019. 18 LEGISLATIVE ANALYST’S OFFICE AN LAO REPORT Traffic Congestion Declined Figure 20 During Pandemic. Why are so many people speeding? Perhaps Growth in Motorist Deaths and Growth in Pedestrian it could be related to traffic Deaths Have Occurred Under Different Light Conditions congestion. The presence of many Share of 2019 to 2022 Increase in California Motor Vehicle Accident Deaths, vehicles on the road can force Age 15 to 44 drivers to slow down, while the absence of such vehicles can have 30% the opposite effect. We explore this possibility in Figure 22 on 25 the next page. As shown in the 20 figure, quarterly total vehicle hours of delay (a key measure 15 of traffic congestion) on state 10 highways plummeted by more than 75 percent in the middle 5 of 2020. Much like the trend in overall driving, highway traffic Daylight Dark, Lit Dark, Not Dawn or Daylight Dark, Lit Dark, Dawn or Lit or Unknown Dusk Not Lit or Dusk congestion experienced only a Unknown partial rebound. Although vehicle Motor Vehicle Occupants Pedestrians hours of delay rose after the initial (including Motorcyclists) months of the pandemic, they were Source: Fatality Analysis Reporting System. still 34 percent lower in 2023 than in 2019. This persistent decline in traffic congestion potentially could Figure 21 be contributing to higher rates of California Highway Patrol (CHP) Citations for Driving speeding and higher death rates. Over 100 Miles Per Hour Still Exceed Pre-Pandemic Level Growth in Motor Vehicle Deaths Spread Across Many Annual Citations Issued by CHP for Driving Over 100 Miles Per Hour Types of Traffic Violations. After every fatal crash, law enforcement 30,000 agencies determine which type of 25,000 traffic violation was the “primary collision factor” leading to the 20,000 crash. As noted above, many factors can contribute to crashes, 15,000 some of which fit neatly into this 10,000 framework and some of which do not. Nevertheless, this information 5,000 can help us make some progress towards understanding the trend in 2018 2019 2020 2021 2022 2023 motor vehicle deaths. As shown in Figure 23 on Source: California Highway Patrol. the next page, California’s pandemic-era growth in age 15 to be a secondary factor contributing to many of the 44 motor vehicle fatalities is spread across many other deaths. For example, improper turning—such different primary collision factors. The one that as failing to navigate a curve properly or swerving lines up most clearly with the discussion above is to avoid an object in the roadway—accounts for the “unsafe speed,” which accounts for 9 percent of the biggest share of the growth, 27 percent. growth. Additionally, driving at unsafe speeds could www.lao.ca.gov 19 AN LAO REPORT at the overall pattern, the growth Figure 22 appears to be spread across many different primary collision factors, Traffic Congestion on State Highways including some whose connection Still Well Below Pre-Pandemic Levels to speeding is tenuous at best. The Total Vehicle Hours of Delay (In Millions) most straightforward interpretation is that a broad increase in various 45 types of risky driving behaviors likely 40 accounts for a substantial portion of 35 the mortality trend. 30 Law Enforcement Stopping 25 Fewer Drivers for Moving 20 Violations Since the Pandemic. 15 As we explore potential explanations 10 for the rise in age 15 to 44 motor 5 vehicle deaths, another key factor to consider is traffic enforcement. Law 2018 Q1 2018 Q3 2019 Q1 2019 Q3 2020 Q1 2020 Q3 2021 Q1 2021 Q3 2022 Q1 2022 Q3 2023 Q1 2023 Q3 enforcement agencies’ strategies for enforcing traffic laws involve various Source: California Department of Transportation, Performance Measurement System. activities that interact with each other in complex ways, so any attempt to quantify enforcement will have some Figure 23 serious limitations. That said, trends Growth in Motor Vehicle Deaths Spread in stops for moving violations can Across Many Types of Traffic Violations give us a reasonable starting point for understanding changes in traffic Share of 2019 to 2022 Growth in Age 15 to 44 Motor Vehicle Deaths, by Primary Collision Factor enforcement activities over time. Figure 24 displays trends in the total number of stops for moving 30% violations by CHP and by the state’s 25 seven largest local law enforcement 20 agencies. CHP stops dropped 25 percent in the second quarter 15 of 2020 but mostly rebounded in 10 the third quarter of 2020. Since 5 then, stops have been trending slightly downward and were about Improper Driving or Pedestrian Unsafe Traffic Wrong Side Unsafe Other 10 percent below pre-pandemic Turning Bicycling Violation Speed Signals of Road Lane Under Influence and Signs Change levels in 2022 (the most recent year of Alcohol for which data are available). or Drug Source: Data summary provided by California Highway Patrol (CHP), including reports originating from CHP Stops for moving violations made and from allied local law enforcement agencies. by the state’s seven largest local law enforcement agencies dropped Higher speeds plausibly could increase the risk 32 percent in the second quarter of a fatality from improper turning. Likewise, even of 2020. Unlike the CHP trend, however, stops by when pedestrian violations—such as jaywalking— local law enforcement did not rebound after this are the primary collision factor, faster-moving mid-2020 dip, with stops remaining at a depressed vehicles presumably have a harder time stopping or level through 2022. These persistent declines slowing down to avoid fatalities. That said, looking 20 LEGISLATIVE ANALYST’S OFFICE AN LAO REPORT declined over this period, with the Figure 24 declines ranging from 23 percent to 86 percent. Moving violation Stops for Moving Violations Are Below Pre-Pandemic Levels stops by two of the agencies Quarterly Total Stops for Moving Violations (Los Angeles County Sheriff and Riverside County Sheriff) grew over 400,000 California Highway Patrol this period. 350,000 Enforcement Among Several 300,000 Factors Potentially Driving 250,000 Mortality Trend. At the beginning 200,000 of this section, we observed 150,000 that young adult motor vehicle 7 Largest Local Agencies Combined 100,000 deaths rose abruptly in 2020 and have been roughly flat since. 50,000 This trajectory lines up rather 2018 Q3 2019 Q1 2019 Q3 2020 Q1 2020 Q3 2021 Q1 2021Q3 2022 Q1 2022 Q3 closely with the trend in local stops for moving violations, so changes in Note: The seven largest local law enforcement agencies are the Los Angeles Police Department, the Los Angeles County Sheriff's Department, the San Diego Police Department, the Riverside County Sheriff's Department, the enforcement activities conceivably San Francisco Police Department, the San Bernardino County Sheriff's Department, and the San Diego County Sheriff's Department. could be contributing to the trend Source: California Department of Justice data collected pursuant to the Racial and Identity Profiling Act in motor vehicle deaths. That said, Chapter 466 of 2015 (AB 953, Weber). there are a couple of reasons to think that enforcement might not in stops are particularly striking given that the be the primary explanation for mortality data do not seem to suggest any decline these trends. First, various other factors—such as in dangerous driving—if anything, the opposite. the decline in traffic congestion noted earlier—also The declines could be driven by various factors, have coincided with the mortality trend and likely including staffing levels or policy changes. have played a substantial role. Second, crashes Trends in Stops Vary Across Local Law on state highways—where CHP is responsible for Enforcement Agencies. Moving violation stops traffic enforcement—account for a slight majority by five of the seven agencies (Los Angeles Police of the growth in motor vehicle deaths. Most of the Department, San Diego Police Department, San increase in motor vehicle deaths occurred in the Francisco Police Department, San Bernardino second half of 2020, when CHP stops were around County Sheriff, and San Diego County Sheriff) the same level as before the pandemic. ISSUES FOR LEGISLATIVE CONSIDERATION Young Adult Mortality Warrants Substantial require substantial additional research. At the same Attention From State Leaders and Researchers. time, the urgency of the problem compels us to In California and the rest of the nation, age 15 to recommend that state leaders start to consider 44 mortality is still much higher than before potential policy responses immediately. the COVID-19 pandemic. This trend has been Explore Options in Key Policy Areas… especially pronounced for men, Native American Breaking down the mortality trend by causes of and Black Californians, and residents of rural death, we have highlighted the importance of drug northern counties and the state’s lowest-income overdoses, alcohol-induced deaths, and motor zip codes. This report presents information about vehicle crashes. One of the major factors driving some potential explanations for these trends, but the overdose trend has been the growing presence developing a full understanding of its origins will of fentanyl in California’s illicit opioid markets. www.lao.ca.gov 21 AN LAO REPORT Extreme speeding and other risky driving behaviors of the size and seriousness of the overall problem likely have played significant roles in the trend and of the stark disparities between groups. in motor vehicle deaths. These trends present For researchers, we note that changes in several major challenges for the Legislature to tackle seemingly disparate types of risky behavior have through policies and programs related to drugs, persisted several years past the onset of the alcohol, and traffic safety. In the 2025-26 session, pandemic. Future research could explore potential we encourage the Legislature to explore options connections among these behaviors, as well as the in these areas both through the budget and extent to which they could be due to the COVID-19 policy processes. virus itself, policy responses to the pandemic, or …But Also Consider Issue More Broadly. other social changes that have occurred in 2020 The specific areas listed above are a natural starting and beyond. point for responses to the young adult mortality For policymakers, we note that responses to problem. A key purpose of this report, however, has young adult mortality need not be limited to the been to illustrate a broader picture than those we areas listed above. The Legislature also could look can see through specialized policy lenses. By taking for opportunities to address this problem through this view, we hope that readers have gotten a sense other areas of health policy and public safety policy. 22 LEGISLATIVE ANALYST’S OFFICE AN LAO REPORT APPENDIX Data Describing These reporting requirements do not apply when health care practitioners administer the drugs Medication-Assisted Treatment directly, rather than dispensing them to patients. Data From Two Complementary Sources. They also do not apply when patients receive drugs To analyze trends in medication-assisted treatment, from a SAMHSA-funded substance use treatment we explore data from two sources. These sources facility. Given these limitations, our CURES analysis describe two different parts of the treatment focuses on buprenorphine, which we understand landscape, with largely complementary strengths to be more widely used for opioid use disorder than and weaknesses. naltrexone and available in a wider range of clinical Surveys of Treatment Facilities. The federal settings than methadone. We review aggregate Substance Abuse and Mental Health Services CURES data on buprenorphine prescriptions from Administration (SAMHSA) conducts an annual two sources: (1) the California Department of Public survey that elicits information from all dedicated Health’s (CDPH) Overdose Surveillance Dashboard substance use treatment facilities. Before 2021, and (2) a paper by Wang et al. (2024). SAMHSA collected this information through the National Survey of Substance Abuse Treatment Conflicting Evidence on Services. Starting in 2021, SAMHSA combined Buprenorphine Prescription Trends this survey with another one to form the National Different Trends Despite Same Underlying Substance Use and Mental Health Services Data. CDPH’s Overdose Surveillance Dashboard Survey. Among other things, these surveys ask and a paper by Wang et al. (2024) present facilities about the number of patients enrolled in conflicting information about statewide trends substance use treatment in late March of each year. in buprenorphine prescriptions. The substantial Notably, these surveys do not capture treatment differences in the trends presented by these two provided in other types of clinical settings (for sources are puzzling given than they both use the example, by primary care physicians). They also same underlying data source: the state’s CURES do not specify patients’ ages, so our analyses of database. We describe the disparate trends and medication-assisted treatment are not age-specific. some technical data issues below. As with all survey data, the reliability of these Dashboard Indicates Large Jump in measurements depends heavily on the accuracy Buprenorphine Prescriptions in Early 2021. and representativeness of responses. One CDPH’s Overdose Surveillance Dashboard encouraging sign is that response rates for this summarizes quarterly statewide total buprenorphine survey tend to be high. Although the survey prescriptions from CURES. The most prominent response rate dipped a bit in 2021 (to 74 percent), feature of this summary is a large jump in the first the response rates in 2020 and 2022 were very quarter of 2021. According to the Dashboard, similar to 2019 (all 85 to 86 percent). Consequently, buprenorphine prescriptions rose 35 percent from we think that changes in survey nonresponse the fourth quarter of 2020 to the first quarter of likely are not driving the overall pattern shown 2021. We have not found a satisfactory explanation in Figure 12. for this abrupt increase. Several policy changes State Prescription Database. The state plausibly could have expanded access to maintains a prescription database known as the buprenorphine substantially in recent years, but Controlled Substance Utilization Review and the timing of these changes does not line up very Evaluation System (CURES). In many cases, well with this jump in the data. Additionally, a state pharmacists and other health care practitioners law (Chapter 677 of 2019 [AB 528, Low]) changed must report their dispensing of controlled some CURES reporting requirements effective substances to be included in this database. www.lao.ca.gov 23 AN LAO REPORT January 1, 2021, but we would not expect this law Selected References to have major effects on buprenorphine reporting. Ahmad, Farida, Jodi Cisewski, Lauren Rossen, Aside from the sharp increase described and Paul Sutton (2024). “Provisional Drug Overdose above, notable features of the Dashboard Death Counts.” National Center for Health summary include: Statistics. • Growth throughout 2018. Badger, Emily, Ben Blatt, and Josh Katz (2023). “Why Are So Many American Pedestrians Dying at • A decline in 2019. Night?” The New York Times, December 11, 2023. • Stagnation from late 2019 through 2020. California Department of Public Health, Office • Growth throughout 2021 and beyond. of Policy and Planning (2024). California State of Study Using Same Data Source Displays Public Health Report, 2024. Very Different Trend. Figure 1, Panel C in Wang Case, Anne and Angus Deaton (2015). “Rising et al (2024) displays monthly buprenorphine Morbidity and Mortality in Midlife Among White prescriptions from CURES. This figure shows Non-Hispanic Americans in the 21st Century.” no abrupt increase in early 2021. Furthermore, Proceedings of the National Academy of Sciences it shows: 112(49):15078–15083. • Growth in 2019. Fowle, Matthew and Giselle Routhier (2024). • A period of decline from late 2019 through “Mortal Systemic Exclusion Yielded Steep early 2020. Mortality-Rate Increases In People Experiencing • Stagnation through much of 2020, then a Homelessness, 2011–20.” Health Affairs decline at the end of the year. 43:226-233. • Stagnation through 2021. Humphreys, Keith, Chelsea Shover, Christina Andrews, Amy Bohnert, Margaret Brandeau, These patterns are strikingly different from the Jonathan Caulkins, Jonathan Chen, Tom Coderre, ones presented on the Dashboard. That said, as Mariano-Florentino Cuellar, Yasmin Hurd, David noted in the main text of the report, the two sources Juurlink, Howard Koh, Erin Krebs, Anna Lembke, both indicate that buprenorphine prescriptions Sean Mackey, Lisa Larrimore Ouellette, Brian did not increase in 2020 to offset the decline in Suffoletto, and Christine Timko (2022). “Responding facility-based treatment. to the Opioid Crisis in North America and Beyond: What Could Explain These Differences? The Recommendations of the Stanford-Lancet underlying CURES data include various specific Commission.” Lancet 399:555-604. products that health care practitioners prescribe. Spencer, Merianne and Farida Ahmad (2016). Researchers must exercise some discretion “Timeliness of Death Certificate Data for Mortality as they decide which specific product names Surveillance and Provisional Estimates.” National should count as buprenorphine for the purpose of Center for Health Statistics. tracking aggregate trends in medication-assisted Wang, Yun, Alexandre Chan, Richard Buettler, treatment. From follow-up discussions with both Marc Fleming, Todd Schneberk, Michael Nicol, sets of researchers, we understand that the and Haibing Lu (2024). “Real-World Dispensing of Wang et al. (2024) analysis includes a broader Buprenorphine in California During Prepandemic set of buprenorphine products than the CDPH and Pandemic Periods.” Healthcare 12, 241. dashboard. To investigate this issue, CDPH examined an alternative version of their Dashboard summary using a definition of buprenorphine much closer to the one provided by Wang et al. (2024). Unfortunately, however, this alternative analysis still did not come very close to matching the patterns shown in the Wang et al. (2024) figure. The reason for the discrepancy remains elusive. 24 LEGISLATIVE ANALYST’S OFFICE AN LAO REPORT www.lao.ca.gov 25 AN LAO REPORT 26 LEGISLATIVE ANALYST’S OFFICE AN LAO REPORT www.lao.ca.gov 27 AN LAO REPORT LAO PUBLICATIONS This report was prepared by Seth Kerstein with assistance from Will Owens and others in the office, and reviewed by Brian Uhler and Carolyn Chu. The Legislative Analyst’s Office (LAO) is a nonpartisan office that provides fiscal and policy information and advice to the Legislature. To request publications call (916) 445-4656. This report and others, as well as an e-mail subscription service, are available on the LAO’s website at www.lao.ca.gov. The LAO is located at 925 L Street, Suite 1000, Sacramento, California 95814. 28 LEGISLATIVE ANALYST’S OFFICE