"Survivors" of the Opioid Crisis: Epidemiological Paradox and Negative Equality in Overdose Deaths Among Patients with Chronic Musculoskeletal Diseases, 1999–2020

Background. The U.S. opioid crisis has shifted from prescription to illicit sources, yet the long-term mortality trajectory for patients with chronic musculoskeletal conditions (CMC)—the original target of prescribing controls—remains understudied. We aimed to reconstruct overdose mortality trends for CMC patients (1999–2020) and examine structural racial and geographic disparities. Methods. We conducted a retrospective cohort study using CDC WONDER data. We analyzed trends in opioid overdose deaths among CMC patients aged 25–84 years using Joinpoint regression and quantified racial inequalities using Rate Ratios (RR) and Rate Differences (RD). Results. Contrary to national fentanyl-driven surges, CMC opioid mortality declined significantly by 12.8% annually post-2013. This "epidemiological paradox" suggests strict medical controls created "iatrogenic insulation" against illicit markets. Although the White-to-minority mortality gap narrowed significantly (RR from 5.0 to 1.8), this convergence was driven by risk regression among Whites rather than improvements for minorities, representing "Negative Equality." Rural areas experienced asymmetric declines due to severed access, despite persisting "medical deserts." Conclusions. Strict supply-side interventions effectively reduced overdose deaths among CMC patients but masked persistent structural inequities. Public health policy must shift from generalized restriction to targeted health equity interventions, ensuring the narrowing of racial gaps reflects genuine health improvements rather than shared deprivation.