Fewer Coloradans died in 2023 than in the previous year, but the state still lost more people than it did before the pandemic.

Drug overdoses, COVID-19 and organ damage from alcohol were the biggest culprits behind the still-elevated number of deaths since the pandemic. In contrast, fewer people died last year of chronic diseases such as cancer and heart disease, after accounting for the state population’s growth and aging since 2019.

Last year, 44,862 people died in the state.

Colorado’s death rate peaked in 2021, when COVID-19 killed thousands of people, before dropping again in the next two years. But 5,544 more people still died in 2023 than had in 2019 — a 7% increase, after adjusting for population changes, according to newly finalized data released by the Colorado Department of Public Health and Environment.

Both men and women had higher death rates in 2023 than they did in 2019; the state’s data doesn’t break out nonbinary people. So did every age group except infants. Colorado changed how it reported racial data in 2020, so the numbers don’t allow for comparisons before the pandemic.

In 2020, Colorado’s mortality rate rose not only because thousands of people died from COVID-19, but also because deaths increased from heart disease, cancer, strokes and Alzheimer’s disease. Researchers haven’t landed on a single explanation for the increased death from multiple causes, but delayed medical care and complications from the virus could be factors.

Deaths from major natural causes dropped in 2021 and stabilized in 2022, though in most cases they remained above pre-pandemic levels. Last year was the first time since the pandemic began that most major causes of death had lower rates than in 2019, though the increase in overdoses overshadowed that improvement.

Colorado is doing relatively well in addressing the kinds of deaths that people can prevent through healthy habits and routine screenings, and medical advances are allowing people to live longer with diseases like cancer, said Cathy Bradley, dean of the Colorado School of Public Health.

Those same strategies don’t work as well in preventing deaths from drugs or alcohol, she said.

“It’s very different,” she said.

COVID no longer leading cause of death

Cancer overtook heart disease as the top killer in Colorado in 2023, though the death rate for both dropped after adjusting for population growth and aging.

Not enough time has passed to know whether people skipping cancer screenings at the height of the pandemic will lead to more deaths, Bradley said. (In 2023, the adjusted death rate for cancer dropped, though the number of deaths increased because the population is growing and aging.)

In the next few years, people who didn’t catch up on their screenings could start to seek care for advanced cancers that cause symptoms, but improvements in treatment for late-stage disease mean that additional deaths likely won’t happen for another decade, she said.

Accidents other than overdoses and chronic lower respiratory diseases, such as emphysema, retained their spots in third and fourth place among Colorado’s top causes of death in 2023. Strokes and similar conditions took over fifth place, followed by Alzheimer’s disease, accidental overdoses, suicide, chronic liver disease and diabetes.

In 2022, COVID-19 had been the fifth-largest cause of death in Colorado, but last year, it dropped out of the top 10. The state health department recorded 626 deaths from the virus in 2023, compared to 2,261 in 2022, when the state was coping with the tail end of the first wave of the omicron variant.

COVID-19 peaked as the state’s third-leading cause of death in 2021, when only cancer and heart disease killed more Coloradans.

Still, COVID-19 remained a bigger threat last year than other respiratory infections: 370 people died of flu and other diseases that cause pneumonia in 2023. It also explained about one-fifth of the excess deaths in 2023 compared to 2019, when the virus hadn’t yet arrived in Colorado.

COVID-19 likely will remain a threat for the foreseeable future, particularly to older people, Bradley said. The best way to address that is to continue to develop vaccines that are well-targeted to the latest versions of the virus, and to encourage people to get them, she said.

Deaths from cancer, heart disease, chronic lower respiratory disease, Alzheimer’s, suicide and diabetes were all down compared to both 2022 and 2019, after adjusting for population changes.

Stroke deaths were up slightly compared to the previous year and before the pandemic, while unintentional overdoses increased significantly. Chronic liver disease deaths were up compared to 2019, but down slightly from their high in 2022.

Overdoses were the largest source of Colorado’s excess death last year compared to 2019, explaining more than one-quarter of the rise. Strokes, in contrast, only accounted for about 3% of the difference.

Alcohol-related deaths, which included some cases of liver disease as well as other types of organ damage, explained 12% of the difference.

Heavy drinking jumped in 2020, though young people seem to be cutting back, perhaps in response to a growing scientific consensus that alcohol isn’t a health food, Bradley said. She isn’t sure if that information will change the behavior of older people, who aren’t curbing their drinking at this point.

“For a very long time, we believed alcohol had positive health effects,” she said.

Alcohol is available in more outlets in Colorado than it ever has been, and drinking levels that people perceive as normal can bring health risks over time, said Marc Condojani, interim director of statewide programs at the Colorado Behavioral Health Administration.

To bring down deaths, the state needs more treatment capacity for people with more severe alcohol use disorders, a shift in people’s perception of what constitutes low-risk drinking and to involve more health care providers in screening and counseling patients before heavy use turns into addiction, he said.

“We want to make sure we’re using all the tools in the toolbox,” he said.

Fentanyl fuels increase in OD deaths

The increase in death rates since 2019 wasn’t limited to a particular demographic.

Both men and women showed a similar pattern, with improvement compared to 2022, but worsening compared to 2019. The impact was slightly greater for men, though: their death rate remained about 9% higher than it was before the pandemic, compared to about 5% for women.

Death rates decreased from 2022 to 2023 for all age groups except infants and youth between 15 and 18. Compared to 2019, however, mortality rates were up for all groups except infants. (Deaths before a child’s first birthday are relatively rare, so the rate has more random fluctuation than in older age groups.)

Accidental overdoses were the top driver of increased deaths in people between 15 and 64. The top driver for children between 1 and 14 was homicide, and COVID-19 remained the largest cause of excess death for people 65 and older.

Usually, when one cause is increasing death rates for a large swath of the population, that cause is something like a new virus, Bradley said. Overdoses are different, because society’s existing problems, like untreated mental health conditions and addictions, are driving the deaths, she said.

“It’s not an infectious disease that’s spreading like wildfire through our society,” she said. “It’s something that’s arising in our society.”

The rate of Colorado’s overdose deaths had decreased slightly in 2022, raising hopes that the worst of the opioid epidemic might be over. The 2023 numbers, which showed overdoses increasing about 3%, dashed those hopes.

The biggest culprit was fentanyl, which killed nearly 1,100 people in Colorado, though deaths involving methamphetamine and cocaine also increased.While some people do die solely from a stimulant overdose, many of those deaths were in people who bought meth or cocaine that also contained fentanyl, Condojani said.

“This is probably our new normal because that just seems to be the way the data have been running the past few years,” said Dr. Tyler Coyle, an addiction medicine physician at the University of Colorado’s Anschutz Medical Campus and the president of the Colorado Society of Addiction Medicine. “I don’t like saying it, but that seems to be the message that I’m taking away from (the data), that this is just where things are now. It highlights the need for us to start looking at newer and alternative solutions that have not been acted on so far.”

Colorado is taking steps to reduce overdoses, such as distributing reversal medications more widely and increasing youth education about the risk that pills that don’t come from a pharmacy could contain fentanyl, Condojani said. The Behavioral Health Administration also is trying to change views about addiction, so people who need help don’t feel ashamed asking for it and have more hope for recovery, he said.

“Recovery is more than possible. It’s the expectation,” he said.

“It’s hard to change society”

Most racial and ethnic groups’ death rates dropped from 2022 to 2023, with the exception of Native Americans and Native Hawaiians/Pacific Islanders. Those groups are the smallest, by population, in Colorado, so their mortality numbers are more prone to fluctuations.

Colorado changed how it groups data by race and ethnicity in 2020, so it doesn’t allow for pre-pandemic comparisons.

Still, significant disparities remained unchanged, with Black, Native American and Pacific Islander Coloradans having the highest death rates, while white, Asian and multiracial residents of the state had the lowest adjusted rates.

To fully close disparities in mortality, Colorado would have to first address them in other areas of life that contribute to poor health, such as education and housing, Bradley said. That kind of broad change isn’t likely to happen quickly, but the state could make significant progress if it ensured everyone had access to health insurance, she said.

“It’s hard to change society all at once,” she said.

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Originally Published: June 23, 2024 at 6:00 a.m.