This project was born the day a reader filled out the survey at the bottom of our story No Autopsy, No Answer about Nebraska’s coroner system. He wrote, “I’m a drug harm reduction community organizer and have lost 96 friends to overdose. 71 have nothing on their death certificate that says anything about drugs as a cause of death.”
I gave the reader, Paul Weishapl, a call. He turned out to be an instructor at the University of Nebraska Medical Center who’s working to raise awareness of the trend he was seeing. Everyone agreed, Weishapl said: There’s broad undercounting of drug deaths across the state.
But that theory was mostly untested. My first question: What actually is an overdose?
Each death certificate in America features an immediate cause — the final event that caused the person to die, like a heart attack, and several lines of underlying causes — circumstances that led up to the death like heart disease or history of smoking. No matter what that immediate cause was, experts told me, a person on drugs should have them appear as underlying causes.
The main source of information I pulled from is the CDC’s WONDER database Underlying Cause of Death, 2018-2023, which aggregates information from death certificates filed in every state.
After talking with researchers who work with this data, I decided to select for “drug-induced causes,” which includes both intentional and unintentional drug overdoses and poisonings. I also chose to look at all drugs, not just opioid-specific overdoses. Nebraska has a high prevalence of both methamphetamine and pharmaceuticals like Xanax. Often, our deaths include multiple drugs. Even more often, Nebraska’s death certificates do not specify the drug at all.
At the national level, a clear narrative emerged: Year after year, Nebraska trades places with South Dakota for the lowest overdose rate in the country. Every source I talked to said those numbers aren’t true, there are more deaths that are being missed.
But how do you show something that isn’t there?
Forensic pathologist Dr. Erin Linde thinks about it in terms of who’s overdosing but isn’t dying. She pointed me to a report from the state looking at five years of emergency medical services data on nonfatal overdoses. It isn’t a perfect picture because the state provides only ranges of rates, like 54.8 to 89.7 overdoses per 100,000 people, for each of the state’s local health districts. But when contrasted with counties’ death rates from the CDC data, like in the map below, it tells a story of regions where people are overdosing but seemingly not dying.
Another way to examine who’s overdosing but surviving is the CDC’s DOSE data, which pulls from hospitals around the country. That’s a problem for taking a closer look at Nebraska, where DHHS says as many as 16 counties have no hospitals at all.
Another major issue with looking at county-level data in Nebraska is data suppression for privacy. Many counties have so few residents that we’re looking at fewer than 10 nonfatal overdoses per year. The CDC suppresses public health information where between one and nine people are impacted to help prevent those people from being identified. I chose to focus my analysis on Nebraska’s 10 most populous counties to avoid that suppression threshold, and to pull data from a range of years, 2019-2023.
With census data, I pulled an average population for each county in the United States over that time period and matched those populations with Nebraska counties to find their peers. Then, I patched in death rates from CDC’s WONDER for the same timeframe. I lost a few county comparisons to suppression and settled on a small sample set of 40.
From this, I could see that Nebraska consistently has lower fatality ratios than its peers, meaning fewer deaths are reported in relation to nonfatal overdoses. This data does not capture every nonfatal drug overdose, but is the most standardized data.
For an estimate of possible undercounting that’s easier to digest, I found 25 Nebraska counties that each reported no drug-induced deaths over the five years and calculated how many people may have died if those counties followed the statewide trend. Together, those counties may have had 213 missed deaths. Adding those deaths alone to Nebraska’s yearly totals removes our lowest-in-the-nation ranking.
So why does this undercounting matter?
There are a variety of ways that not having accurate public health data trickles down to hurt communities, through things like policy decisions and response times. I wanted to show an impact that people understand intuitively: money.
I decided to look for a macro-level view, using the federal Substance Abuse and Mental Health Services Administration’s grant tracking dashboard. My sources all pointed to treatment as the piece of drug response where they hurt the most for resources. I pulled funding totals for those grants over the past decade through the federal Center for Substance Abuse Treatment.
The substance abuse treatment grants come from a variety of mechanisms. Some require states to apply for funding. Some are block grants calculated for each state or territory with a federal formula that uses a figure called the Population-at-Risk Index. SAMHSA declined to explain to me what exactly goes into that index, but researchers believe overdose fatalities play a role.
I totaled up all of the grants under the Center for Substance Abuse Treatment for each state or territory for the past decade. Then, to both make those multimillion-dollar numbers more digestible and relative to the size of the state, I used state populations to calculate a rough dollar amount received per person. Nebraska received about $63 per person, the lowest of any state and any U.S. territory.
