INEQUALITIES IN BRAZIL’S ILLEGAL DRUG-RELATED ACUTE POISONINGS: AN 18-YEAR NATIONWIDE ANALYSIS
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Abstract
Background Despite rising drug use in Brazil, the proportion of severe acute drug-related poisonings has declined markedly. We investigated whether this improvement has been equitably distributed across ethnic and educational groups. Methods Ecological time-series study using the complete national series of moderate/severe exogenous intoxications notified to SINAN (Brazilian Notifiable Diseases Information System), 2007–2024 (n = 256,575). Severe outcome was defined as hospitalization with sequelae or death. Annual proportions of sociodemographic variables (sex, self-declared race/skin color, education, age) were entered into standardized multivariable linear regression, ridge regression, principal component analysis, and bootstrap (1,000 resamples). Counterfactual scenarios projected preventable severe cases through realistic reductions in low education. Results Notifications increased 15-fold while the severe case proportion fell 50% (11.4% to 5.7%; p < 0.001). Indigenous ethnicity was the only group independently associated with higher severity (standardized β = +2.037, p = 0.038). Youth (15–19 years) conferred the strongest protection (β = –3.315, p = 0.003), but this advantage was almost completely nullified among mixed-race (parda) youth (interaction β = +9.65, p = 0.088). Low education showed strong protective association (β = –1.601, p = 0.073). Counterfactual analysis estimated that 10–50% reductions in low education would avert 14–70 severe cases by 2030. Conclusion Brazil achieved one of the largest and fastest reductions in severe drug-related harm ever documented in a large population, driven by educational expansion and inclusion of marginalized groups into surveillance. Yet this success is profoundly stratified: indigenous individuals and mixed-race youth, the very populations whose inclusion fueled the rise in notifications, continue to bear a disproportionate burden of severe outcomes, revealing an inequality-constrained epidemiological transition.
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Background
Despite rising drug use in Brazil, the proportion of severe acute drug-related poisonings has declined markedly. We investigated whether this improvement has been equitably distributed across ethnic and educational groups.
Methods
Ecological time-series study using the complete national series of moderate/severe exogenous intoxications notified to SINAN (Brazilian Notifiable Diseases Information System), 2007–2024 (n = 256,575). Severe outcome was defined as hospitalization with sequelae or death. Annual proportions of sociodemographic variables (sex, self-declared race/skin color, education, age) were entered into standardized multivariable linear regression, ridge regression, principal component analysis, and bootstrap (1,000 resamples). Counterfactual scenarios projected preventable severe cases through realistic reductions in low education.
Results
Notifications increased 15-fold while the severe case proportion fell 50% (11.4% to 5.7%; p < 0.001). Indigenous ethnicity was the only group independently associated with higher severity (standardized β = +2.037, p = 0.038). Youth (15–19 years) conferred the strongest protection (β = –3.315, p = 0.003), but this advantage was almost completely nullified among mixed-race (parda) youth (interaction β = +9.65, p = 0.088). Low education showed strong protective association (β = –1.601, p = 0.073). Counterfactual analysis estimated that 10–50% reductions in low education would avert 14–70 severe cases by 2030.
Conclusion
Brazil achieved one of the largest and fastest reductions in severe drug-related harm ever documented in a large population, driven by educational expansion and inclusion of marginalized groups into surveillance. Yet this success is profoundly stratified: indigenous individuals and mixed-race youth, the very populations whose inclusion fueled the rise in notifications, continue to bear a disproportionate burden of severe outcomes, revealing an inequality-constrained epidemiological transition.
Competing Interest Statement
The authors have declared no competing interest.
Funding Statement
This study did not receive any funding
Author Declarations
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I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).
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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.
Yes
Data Availability
All data produced in the present study are available upon reasonable request to the authors
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