Increased deaths from COVID-19 and overdoses canceled out progress against other diseases in Colorado last year, meaning the state’s mortality rate barely budged from its 2020 high.

While the raw number of deaths rose by 1,428 from 2020 to 2021, the state’s overall death rate ticked down slightly — from 785.4 deaths per 100,000 people to 784.8, after adjusting for population growth and aging. That’s a small enough change that it could be just statistical noise, according to state health officials

The state’s 2021 mortality data, finalized this month by the Colorado Department of Public Health and Environment, shows middle-aged people were especially hard-hit, the gap in death rates between white Coloradans and people of color narrowed slightly, and men’s life expectancy dropped more than women’s.

2020 was an inarguably bad year, with the pandemic contributing to above-average death rates for all major causes in Colorado except chronic lung disease and the general “influenza and pneumonia” category, which doesn’t include pneumonia caused by COVID-19.

But the year ended with hopes that vaccines would end the days of mass casualties from the virus and deaths from other causes would gradually return to normal as people were able to seek medical care and social support more easily.

That didn’t happen. While the COVID-19 vaccines did dramatically reduce the odds of dying, not enough people got them. A drug supply tainted with fentanyl drove overdose deaths to new heights. And though death rates from most chronic conditions fell in 2021, they didn’t get back to their pre-pandemic levels.

COVID-19 was the biggest factor by far, though.

In 2021, Colorado recorded 48,284 deaths, a figure that was 10,363 more than the pre-pandemic average — and 5,298 of those were caused by the virus. The rise in drug overdoses contributed 911 additional deaths, and increased heart disease deaths added 796.

“It is disconcerting to see (death) rates are still this high at the end of 2021,” said Emily Johnson, director of policy and analysis at the Colorado Health Institute.

Middle-aged adults hit hard

Death rates rose in 2021 for all age groups in Colorado except children between 10 and 17 and adults older than 75.

For younger children, the death rate was unusually low in 2020, mostly because fewer kids were killed in accidents or died by homicide. In 2021, both rebounded to pre-pandemic levels.

Fewer teens died in 2021 than in 2020, after adjusting for population growth, because of decreases in deaths from suicide, homicide, drug overdoses and other accidents. Most causes of death remained above pre-pandemic averages, with the exception of suicide, which last year took Colorado teens at the lowest rate since 2015.

The picture was bleaker for adults.

Most age groups in Colorado had higher death rates than in 2020, which was itself an unusually deadly year. For people between 45 and 74, COVID-19 caused the majority of the deaths beyond what was seen in 2020.

Deaths from the virus more than doubled in the 45-to-64 age group, from 594 in 2020 to 1,432 in 2021, and rose about 52% in people 65 to 74. Middle-aged people were somewhat slower to get vaccinated than the oldest groups, and the more-deadly delta variant walloped them in the summer and fall of 2021.

For adults younger than 45, overdoses were the biggest driver of increased death.

In the first decade of the millennium, overdose deaths were increasing most among women in their 50s, since that was the group most likely to be prescribed opioids, said Dr. Nora Volkow, director of the National Institute on Drug Abuse. Since about 2011, younger people have been more likely to die as heroin eclipsed prescription pills as the top threat, and then was surpassed by fentanyl, she said.

“We’re seeing, increasingly, groups that were not at risk for overdose are overdosing,” she said.

Death rates actually dropped for people over 75 in Colorado last year compared to 2020, though they remained above pre-pandemic levels. For the 75 to 84 group, the biggest factor was a drop in cancer deaths, which last year fell below the average in the five years before the pandemic. For people over 85, reduced deaths from COVID-19 and Alzheimer’s disease drove the decrease.

It’s possible that the decimation of older populations by COVID-19 in 2020 set the stage for at least a temporary decrease in death rates the following year, said Dr. Rong Xu, a professor of biomedical informatics at Case Western Reserve University’s School of Medicine.

“The population that survived 2020 may be healthier,” she said.

Men’s COVID, overdose deaths rose faster

The death rate among Colorado men increased slightly from 2020, while women’s death rate fell by a small amount, but neither was statistically significant. (The state’s data doesn’t account for people who are intersex or transgender.)

When comparing life expectancy, however, a bigger gap emerges. Colorado women lost roughly one month of life expectancy in 2021, bringing the average to 80.9 years. Men lost closer to 10 months, falling to 75.2 years.

Drug overdoses were a significant factor in the expanding gap. Fatal overdose rates rose about 59% above pre-pandemic levels among women and 95% among men. Since men were more likely to die of overdoses before the pandemic — as they have nationwide since at least the late 1990s — that translated to roughly double the death rate from drug poisoning that women faced in 2021.

Men have been more likely to use illicit drugs than women for a long time, and with more people exposed, there are more deaths, Volkow said. The gender gap was narrower when prescription drugs were the top threat, but has expanded over the past decade, she said.

The gender gap was smaller, but still significant, when it came to COVID-19. There were about 107 deaths from the virus for every 100,000 men in Colorado last year and 62 deaths for every 100,000 women.

The biggest risk factor for dying of COVID-19 is age, and women live longer than men, meaning they’ve hardly been spared from the virus.

The gender gap is most evident when looking at people ages 45 to 64, said Richard Reeves, a senior fellow at the Brookings Institute who has written a book about men’s health. While both sexes were about equally likely to get the virus, studies in multiple countries have found men are more likely to be hospitalized, need intensive care or die from COVID-19, he said.

“It suggests that it’s not just cultural factors and the way American men are behaving,” he said.

Initially, women made up a disproportionate share of people receiving COVID-19 vaccines. Colorado’s population is split almost 50-50, but 62% of people who’d received a vaccine at the end of January 2021 were women, perhaps because they account for a larger percentage of health care workers and nursing home residents, who were among the first groups allowed to get the shots.

By the end of July 2021, as eligibility opened up, the state was much closer to parity, with women making up 52% of vaccine recipients. The percentage hasn’t changed much since.

There’s no one answer to why men seem to do worse when infected with COVID-19, but a few factors may contribute, said Dr. Michelle Barron, senior medical director of infection prevention and control at UCHealth.

Women generally produce more antibodies after vaccination or infection, which may help their immune systems stop the virus early — but also put them at higher risk for conditions where the immune system attacks the body itself. There’s also some evidence that estrogen may help tamp down runaway inflammation that causes severe lung scarring, she said.

It’s also possible that the average man who got the virus had more underlying conditions than the average woman, or that smoking rates may be a factor, Barron said. Most respiratory viruses don’t have this kind of gender gap, though, so it’s going to take time to sort out where it might come from, she said.

“I don’t think we’ve come to any definitive conclusion yet as to the ‘why,’” she said.

Continued disparities in life expectancy

Most ethnic groups in Colorado saw lower overall death rates in 2021 than in 2020, but the drops varied significantly, and long-standing disparities remained in place.

In 2020, life expectancy dropped most for Black and Hispanic Americans. In 2021, however, those groups held steady while life expectancy dropped among white Americans — though the 2020 drop was severe enough that the impact on Black and Hispanic communities was still larger.

In Colorado, life expectancy increased slightly for the Black and Asian populations from 2020 to 2021, and held steady for white women. All other groups saw life expectancy drop, though the existing disparities didn’t change much: multiracial, Asian and white populations continued to have the highest life expectancies, while Black and American Indian residents were projected to live the shortest lives.

Black Coloradans continued to have the highest age-adjusted death rates, despite a nearly 7% improvement from 2020. Death rates among Asian residents dropped by about 9%, while for white and Hispanic Coloradans, the drop was less than 1%. (Rates rose among people who identified as American Indian, Pacific Islanders or multiracial, but the populations are so small that the increases can’t tell us much.)

The narrowing gap between white residents and people of color in Colorado largely reflects a change in the pattern of COVID-19 deaths, Johnson said. Larger drops in deaths from the virus among Black and Asian people suggest vaccination outreach efforts to those communities were generally effective, while there’s still work to be done reaching Latinos and certain subgroups of the white population, she said.

Colorado changed how it collected data about race and ethnicity in 2020, so it’s difficult to make direct comparisons between current and pre-pandemic death rates, Johnson said. Still, even though the numbers aren’t exact, it’s clear death rates increased more for people of color in the first year of the pandemic, she said.

“The gaps widened worse than ever, and then narrowed somewhat” in 2021, she said. “COVID put in stark contrast where those inequities are.”

More accidents, fewer lung disease deaths

Cancer dropped to the second-leading cause of death in 2021, behind heart disease. Despite the widespread availability of vaccines for half of 2021, COVID-19 was the third-leading cause of death again, and the death rate from the virus actually increased more than 10% over its 2020 level.

Colorado’s first COVID-19 deaths weren’t recorded until early March 2020, meaning the virus had about 10 months to wreak havoc, rather than the full year in 2021. Still, most experts thought the worst was over at the start of 2021 because vaccines were starting to reach older people, who were at the highest risk of dying; hospitals had learned how to better treat COVID-19 patients; and some of the population had partial protection from previous infections.

Vaccine uptake was slow in some groups, though, and Colorado and other states started lifting restrictions to control the virus just as the delta variant arrived last year. Delta was more likely to cause severe illness, though vaccines remained highly effective at preventing hospitalizations and deaths.

Accidents other than drug overdoses moved up to become the fourth-leading cause of death, as more people died that way and fewer were lost to chronic lower respiratory diseases, such as emphysema.

Cerebrovascular disease (strokes and related conditions) and Alzheimer’s disease remained in sixth and seventh positions, as they were in 2020. Accidental overdoses overtook suicide as the eighth-highest cause, and chronic liver disease rounded out the top 10 causes of death.

Overdose deaths have been generally trending up since 2000, though they jumped faster in 2020 and 2021. The state reported 1,680 overdoses believed to be accidental, and 201 where the death was ruled a suicide in 2021.

Almost half of the fatal overdoses in 2021 included fentanyl, and about 40% involved methamphetamine. About 17% involved both.

Fentanyl is cheap and easy to ship by mail, so drug dealers are mixing it with other illicit drugs or pressing it into pills that look like medications for pain, anxiety or attention deficit disorder, Volkow said. It only costs about $1.25 to make a fake pill out of fentanyl, so dealers can offer it at a significant mark-up and still have a cheaper product than people selling real pills that have been stolen, she said.

Some people choose to mix substances like fentanyl and methamphetamine, while others tried to buy one drug and unknowingly took more, increasing their risk of death, Volkow said. People are also at increased risk if they take certain medications, such as benzodiazepines for anxiety or gabapentin for pain or seizures, and then take legal or illicit opioids, she said. Drinking alcohol while using opioids also increases the odds an overdose will be fatal.

If 2021 was a particularly bad year for overdoses, it was a relatively good one for lung disease in Colorado. The death rate from influenza and pneumonia, one of the only causes to decline in 2020, fell for a fourth straight year. Chronic lower respiratory diseases also resumed the downward trajectory that had been interrupted in 2020, and killed fewer people than before the pandemic, after adjusting for population growth and aging.

Treatment of lung disease has improved in recent years, as newer and easier-to-use medications came on the market, said Dr. Carrie Horn, chief medical officer at National Jewish Health. It’s difficult to know how much of the reduction in lung disease deaths in 2021 was due to a continuation of that trend, versus a mild flu season caused by COVID-19 precautions, or even differences in how death certificates were filled out, she said.

Alzheimer’s disease deaths fell in 2021 and approached pre-pandemic levels, but it’s not clear if that’s a one-time phenomenon. In Colorado and nationwide, they had spiked in 2020.

COVID-19 appears to speed up the process of decline in people with Alzheimer’s, so it may have pushed some people who otherwise might have lived longer to the end stage of the disease in 2020, Xu said. By 2021, vaccines and treatments made the virus less of a threat, which may have helped lower the toll from causes like Alzheimer’s, she said.

“Probably COVID played a big role,” she said.

When will “normal” return?

It’s not clear whether death rates will return to pre-pandemic levels in 2022. Economic downturns typically lead to increases in violent crime, overdoses and delayed medical care, so if there is a recession this year, it would work against any positive trends, Johnson said.

So far, Colorado has recorded 434 drug overdose deaths halfway through the year. Unfortunately, that doesn’t necessarily mean this year is on track to be less deadly, because it can take months for full toxicology information to come in.

Volkow said she doesn’t expect overdose deaths to decline just because life is more normal. To make a change, the country needs more treatment for people with opioid use disorders; education for people casually buying pills about the danger they may contain undeclared fentanyl; access to fentanyl test strips for illicit drug users; and information about reducing the risk of a fatal overdose for people who choose to use fentanyl, she said.

“I am afraid the patterns (of overdoses) will continue to increase unless there is a very strong investment,” she said. “It’s not going away by itself.”

It’s less clear if the worst of the death toll from COVID-19 is over.

Since Jan. 1, the state health department has reported 2,228 deaths among people who had COVID-19, with more than half recorded in the first two months of the year during the omicron wave. The death toll had fallen steadily since mid-February, though it has started to tick up in recent weeks.

While the tallies include some people who had COVID-19 and died of something unrelated, those are expected to account for a small percentage of deaths with the virus. Barron estimated that fewer than 5% of those who die among people hospitalized with the virus ultimately are found to have died of something else.

The odds of dying from the virus went down as treatment improved and omicron replaced the delta variant, Barron said, but the raw number of deaths at the worst point of the omicron wave over the winter was comparable to delta’s peak in fall 2021, because so many people were infected that even a relatively low mortality rate translated into a high toll.

What happens with COVID-19 deaths this year will depend on several factors, like how well the vaccines available this fall match circulating variants and whether people choose to get them, Horn said. About 75% of Colorado residents over 65 have received a third dose of the shot, though booster uptake is considerably lower in younger age groups. The state doesn’t publish data on fourth doses.

No one knows yet if some of the drops in death from chronic illnesses are a step toward returning to pre-pandemic conditions or a blip. Deaths from Alzheimer’s may actually increase beyond the growth expected from an aging population, as people who experienced cognitive damage from COVID-19 develop dementia earlier than they otherwise might have, Xu said.

It also remains to be seen how much of an impact delayed care will have, Horn said. Waiting longer to start medications and pulmonary therapy for chronic lung disease tends to lead to worse outcomes, but a delay of the same length could be far more damaging for one person than another, she said.

“The earlier we can catch a disease process, the more we can stop that downward slope,” she said.

Horn said she hopes that the dramatic reductions in flu deaths in 2020 and 2021 motivate changes to protect vulnerable people going forward, by showing what’s possible. The age-adjusted death rate from flu was about 17% below the pre-pandemic average in 2020 and 48% below average in 2021.

“It was really impressive to see what masking and social distancing and hand hygiene could do,” she said.

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