Understanding and Addressing Widening Racial Inequalities in Drug Overdose.

The fourth wave of the United States overdose crisis-driven by the polysubstance use of fentanyl with stimulants and other synthetic substances-has driven sharply escalating racial/ethnic inequalities in drug overdose death rates. Here the authors present a detailed portrait of the latest overdose trends and synthesize the literature to describe where, how, and why these inequalities are worsening. By 2022 overdose deaths among Native and Black Americans rose to 1.8 and 1.4 times the rate seen among White Americans, respectively. This reflects that Black and Native Americans have been disproportionately affected by fentanyl and the combination of fentanyl and stimulants at the national level and in virtually every state. The highest overdose deaths rates are currently seen among Black Americans 55-64 years of age as well as younger cohorts of Native Americans 25-44 years of age. In 2022-the latest year of data available-deaths among White Americans decreased relative to 2021, whereas rates among all other groups assessed continued to rise. Moving forward, Fundamental Cause Theory shows us a relevant universal truth of implementation science: in socially unequal societies, new technologies typically end up favoring more privileged groups first, thereby widening inequalities unless underlying social inequalities are addressed. Therefore, interventions designed to reduce addiction and overdose death rates that are not explicitly designed to also improve racial/ethnic inequalities will often unintentionally end up worsening them. Well-funded community-based programs, with Black and Native leadership, providing harm reduction resources, naloxone, and medications for opioid use disorder in the context of comprehensive, culturally appropriate healthcare and other services, represent the highest priority interventions to decrease inequalities.

Prescription Opioid Diversion Sources Among African Americans: Implications for Overdose Prevention.

Recent data show that African Americans (AAs) experienced a greater increase in overdose deaths involving prescription opioids relative to other racial/ethnic groups. One possible mechanism through which elevated risk for overdose is conferred to AAs could be due to greater exposure to contaminated counterfeit pills. Unfortunately, prescription opioid diversion is understudied among AAs and less is known regarding which sources AAs use to access pharmaceutical opioids. The objective of this study, therefore, was to identify and describe the most commonly used diversion sources for prescription opioids among AAs. Qualitative interview data are also presented to contextualize the most prevalent sources. This study used data from the Florida Minority Health Study, a mixed-methods project that included online surveys (n = 303) and qualitative in-depth interviews (n = 30) of AAs. Data collection was conducted from August 2021 to February 2022 throughout Southwest Florida. Analyses revealed that the most widely used sources for prescription opioids were dealers (33.0%) and friends/relatives (34.7%). Additionally, interview data indicated that dealers are the access point where larger volume acquisitions are made and high potency formulations are accessed. These findings suggest that AAs may utilize nonhealthcare related sources at higher rates than healthcare related sources to acquire prescription opioids. This is concerning because opioid pills acquired through nonhealthcare related sources are especially susceptible to fentanyl adulteration. These findings invite further study using nationally representative data to determine if AAs disproportionately use nonhealthcare related sources compared to persons from other racial/ethnic groups.

Racial and Ethnic Disparities in Accidental and Undetermined Drug Overdose Deaths - Rhode Island, 2016-2021.

BACKGROUND: Over the last 21 years, drug overdose deaths have increased nationwide, particularly in Rhode Island (RI). The goal of this work is to identify populations that are disproportionately impacted by accidental drug overdose deaths to guide future intervention efforts.  Methods: We obtained data on accidental and undetermined drug overdose deaths from the RI State Unintentional Drug Overdose Reporting System (SUDORS) database from 2016 to 2021. We compared basic demographic factors stratified by decedent race and ethnicity. Chi Square and Fisher's exact tests were used to determine differences in characteristics across racial groups. FINDINGS: Across all race and ethnic groups, cocaine-involved (64.5%) fatal overdoses were higher among Black non-Hispanics. White, non-Hispanics (31.4%) were more likely to receive treatment for substance use disorder (SUD) when compared to minority groups. CONCLUSION: To help address the gaps in treatment for SUD among minority groups, culturally responsive intervention efforts should prioritize connecting minority groups to treatment.

Overdose deaths involving synthetic opioids: Racial/ethnic and educational disparities in the eastern and western US.

BACKGROUND: This study examined racial/ethnic and educational disparities in US synthetic opioid overdose mortality East and West of the Mississippi River. METHODS: Using restricted-access 2018-2021 mortality data from the Centers for Disease Control and Prevention and population estimates from the American Community Survey, age-standardized rate ratios (SRRs) and 95% Confidence Intervals (CIs) were used to compare rates of synthetic opioid mortality by race/ethnicity and educational attainment level in the regions East and West of the Mississippi River. RESULTS: Racial/ethnic disparities in synthetic opioid mortality rates, relative to the Non-Hispanic (NH) White population, were observed in the NH Black (SRR, 1.5 [95% CI, 1.5-1.6]) and NH American Indian/Alaska Native (SRR, 2.1 [95% CI, 1.9-2.2]) populations in the West, and the Puerto Rican (SRR, 1.3 [95% CI, 1.3-1.3]) and NH American Indian/Alaska Native (SRR, 1.5 [95% CI, 1.4-1.6]) populations in the East. Relative to those with a Bachelor's degree or higher: in the West, the synthetic opioid mortality rate was more than seven times as high for those with a high school diploma only (SRR 7.7 [95% CI, 7.4-8.0]), and in the East, approximately thirteen times as high for those with a high school diploma only (SRR, 13.0 [95% CI, 12.7-13.3]) or less than a high school diploma (SRR, 13.3 [95% CI, 13.0-13.7]). CONCLUSION: Disparities in rates of synthetic opioid mortality differ in the eastern and western US, supporting tailored responses within each region.

Years of life lost due to deaths of despair and COVID-19 in the United States in 2020: patterns of excess mortality by gender, race and ethnicity.

BACKGROUND: In 2020 COVID-19 was the third leading cause of death in the United States. Increases in suicides, overdoses, and alcohol related deaths were seen-which make up deaths of despair. How deaths of despair compare to COVID-19 across racial, ethnic, and gender subpopulations is relatively unknown. Preliminary studies showed inequalities in COVID-19 mortality for Black and Hispanic Americans in the pandemic's onset. This study analyzes the racial, ethnic and gender disparities in years of life lost due to COVID-19 and deaths of despair (suicide, overdose, and alcohol deaths) in 2020. METHODS: This cross-sectional study calculated and compared years of life lost (YLL) due to Deaths of Despair and COVID-19 by gender, race, and ethnicity. YLL was calculated using the CDC WONDER database to pull death records based on ICD-10 codes and the Social Security Administration Period Life Table was used to get estimated life expectancy for each subpopulation. RESULTS: In 2020, COVID-19 caused 350,831 deaths and 4,405,699 YLL. By contrast, deaths of despair contributed to 178,598 deaths and 6,045,819 YLL. Men had more deaths and YLL than women due to COVID-19 and deaths of despair. Among White Americans and more than one race identification both had greater burden of deaths of despair YLL than COVID-19 YLL. However, for all other racial categories (Native American/Alaskan Native, Asian, Black/African American, Native Hawaiian/Pacific Islander) COVID-19 caused more YLL than deaths of despair. Also, Hispanic or Latino persons had disproportionately higher mortality across all causes: COVID-19 and all deaths of despair causes. CONCLUSIONS: This study found greater deaths of despair mortality burden and differences in burden across gender, race, and ethnicity in 2020. The results indicate the need to bolster behavioral health research, support mental health workforce development and education, increase access to evidence-based substance use treatment, and address systemic inequities and social determinants of deaths of despair and COVID-19.

Years of life lost due to unintentional drug overdose among perinatal individuals in the United States.

BACKGROUND: The United States has one of the highest maternal mortality rates of developing countries, but the contribution of perinatal drug overdose is not known. Communities of color also have higher rates of maternal morbidity and mortality when compared to White communities, however the contribution due to overdose has not yet been examined in this population. OBJECTIVES: To quantify the years of life lost due to unintentional overdose in perinatal individuals from 2010 to 2019 and assess for disparity by race. STUDY DESIGN: This was a cross-sectional retrospective study with summary-level mortality statistics for the years 2010-2019 obtained from the Centers for Disease Control (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER) mortality file. A total of 1,586 individuals of childbearing age (15-44 years) who died during pregnancy or six weeks postpartum (perinatal) from unintentional overdose in the United States from January 1, 2010 to December 31, 2019 were included. Total years of life lost (YLL) was calculated and summated for White, Black, Hispanic, Asian/Pacific Islander, and American Indian/Native Alaska women. Additionally, the top three overall causes of death were also identified for women in this age group for comparison. RESULTS: Unintentional drug overdose accounted for 1,586 deaths and 83,969.78 YLL in perinatal individuals from 2010 to 2019 in the United States. Perinatal American Indian/Native American individuals had a disproportionate amount of YLL when compared to other ethnic groups, with 2.39% of YLL due to overdose, while only making up 0.80% of the population. During the last two years of the study, only American Indian/Native American and Black individuals had increased rates of mortality when compared to other races. During the ten-year study period, when including the top three causes of mortality, unintentional drug overdoses made up 11.98% of the YLL overall and 46.39% of accidents. For the years 2016-2019, YLL due to unintentional overdose was the third leading cause of YLL overall for this population. CONCLUSIONS: Unintentional drug overdose is a leading cause of death for perinatal individuals in the United States, claiming nearly 84,000 years of life over a ten-year period. When examining by race, American Indian/Native American women are most disproportionately affected.

US drug overdose mortality rose faster among hispanics than non-hispanics from 2010 to 2021.

BACKGROUND: Historically, overdose mortality rates among Hispanics have been lower than non-Hispanics. The purpose of this analysis was to characterize the U.S. overdose crisis among Hispanics compared to non-Hispanics. METHODS: We used the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiological Research (WONDER) platform to obtain drug overdose mortality rates per 100,000 population between 2010 and 2021 for Hispanics and non-Hispanics. We examined the relative percent change and specific drug involvement (2010-2021) and state-level disparities (2010-2020) among Hispanics versus non-Hispanics. We calculated rate ratios by state and annual percent change in total and for each specific drug. Statistical analyses were performed using R software version 4.0.3 (R Project for Statistical Computing). RESULTS: Nationally, from 2010 to 2021, Hispanic overdose rates rose from 5.6 to 21.7 per 100,000, an increase of 287.5 % compared to 13.5-35.1 per 100,000, an increase of 160 % among non-Hispanics. The average annual percent change was 12 % for Hispanics and 9 % for non-Hispanics. The three most common drug classes involved in overdose deaths among both groups included: Fentanyls and synthetic opioids; cocaine; and prescription opioids. Hispanic overdose rates were higher than non-Hispanic rates in New Mexico, Colorado, Massachusetts, and Pennsylvania in 2020, versus only Michigan in 2010. CONCLUSIONS: We observed disparities in overdose mortality growth among Hispanics compared to non-Hispanics from 2010 to 2021. These disparities highlight the urgency to develop community-centered solutions that take into consideration the social and structural inequalities that exacerbate the effects of the opioid overdose crisis on Hispanic communities.

The impact of COVID-19 on healthcare delivery for people who use opioids: a scoping review.

RESEARCH OBJECTIVE: The COVID-19 pandemic disrupted healthcare delivery worldwide with likely negative effects on people who use opioids (PWUO). This scoping review of the original research literature describes the impact of the COVID-19 pandemic on healthcare delivery for PWUO and identifies gaps in the literature. METHODS: This scoping review of the original research literature maps the available knowledge regarding the impact of the COVID-19 pandemic on healthcare delivery for PWUO. We utilized the methodology developed by the Joanna Briggs Institute for scoping reviews, and content analyses methodology to characterize the current state of the literature. RESULTS: Of the 14 included studies, administrative database (n = 11), cross-sectional (n = 1) or qualitative (n = 2) studies demonstrated service gaps (n = 7), patient/provider experiences (n = 3), and patient outcomes for PWUO (n = 4). In March 2020, healthcare utilization dropped quickly, sharply increasing only for reasons of opioid overdose by May 2020. Service gaps existed in accessing treatment for new patients during the pandemic due to capacity and infrastructure limits. Physicians reported difficulty referring patients to begin an outpatient opioid treatment program due to increased restrictions in capacity and infrastructure. Patients also reported uncertainty about accessing outpatient treatment, but that telehealth initiation of buprenorphine increased access to treatment from home. Disproportionate increases in overdose rates among African Americans were reported in two studies, with differences by race and gender not examined in most studies. Fatal overdoses increased 60% in African Americans during the pandemic, while fatal overdoses in Non-Hispanic White individuals decreased. CONCLUSIONS: In summary, this beginning evidence demonstrates that despite early reluctance to use the healthcare system, opioid overdose-related use of healthcare increased throughout the pandemic. Service delivery for medications to treat OUD remained at or above pre-pandemic levels, indicating the ability of telehealth to meet demand. Yet, racial disparities that existed pre-pandemic for PWUO are intensifying, and targeted intervention for high-risk groups is warranted to prevent further mortality. As the pandemic progresses, future research must focus on identifying and supporting subgroups of PWUO who are at heightened risk for experiencing negative outcomes and lack of access to care.

Racial/Ethnic, Social, and Geographic Trends in Overdose-Associated Cardiac Arrests Observed by US Emergency Medical Services During the COVID-19 Pandemic.

Importance: Provisional records from the US Centers for Disease Control and Prevention (CDC) through July 2020 indicate that overdose deaths spiked during the early months of the COVID-19 pandemic, yet more recent trends are not available, and the data are not disaggregated by month of occurrence, race/ethnicity, or other social categories. In contrast, data from emergency medical services (EMS) provide a source of information nearly in real time that may be useful for rapid and more granular surveillance of overdose mortality. Objective: To describe racial/ethnic, social, and geographic trends in EMS-observed overdose-associated cardiac arrests during the COVID-19 pandemic through December 2020 and assess the concordance with CDC-reported provisional total overdose mortality through May 2020. Design, Setting, and Participants: This cohort study included more than 11 000 EMS agencies in 49 US states that participate in the National EMS Information System and 83.7 million EMS activations in which patient contact was made. Exposures: Year and month of occurrence of overdose-associated cardiac arrest; patient race/ethnicity; census region and division; county-level urbanicity; and zip code-level racial/ethnic composition, poverty, and educational attainment. Main Outcomes and Measures: Overdose-associated cardiac arrests per 100 000 EMS activations with patient contact in 2020 were compared with a baseline of values from 2018 and 2019. Aggregate numbers of overdose-associated cardiac arrests and percentage increases were compared with provisional total mortality in CDC records from rolling 12-month windows with end months spanning January 2018 through July 2020. Results: Among 33.4 million EMS activations in 2020, 16.8 million (50.2%) involved female patients and 16.3 million (48.8%) involved non-Hispanic White individuals. Overdose-associated cardiac arrests were elevated by 42.1% nationally in 2020 (42.3 per 100 000 EMS activations at baseline vs 60.1 per 100 000 EMS activations in 2020). The highest percentage increases were seen among Latinx individuals (49.7%; 38.8 per 100 000 activations at baseline vs 58.1 per 100 000 activations in 2020) and Black or African American individuals (50.3%; 21.5 per 100 000 activations at baseline vs 32.3 per 100 000 activations in 2020), people living in more impoverished neighborhoods (46.4%; 42.0 per 100 000 activations at baseline vs 61.5 per 100 000 activations in 2020), and the Pacific states (63.8%; 33.1 per 100 000 activations at baseline vs 54.2 per 100 000 activations in 2020), despite lower rates at baseline for these groups. The EMS records were available 6 to 12 months ahead of CDC mortality figures and showed a high concordance (r = 0.98) for months in which both data sets were available. If the historical association between EMS-observed and total overdose mortality holds true, an expected total of approximately 90 632 (95% CI, 85 737-95 525) overdose deaths may eventually be reported by the CDC for 2020. Conclusions and Relevance: In this cohort study, records from EMS agencies provided an effective manner to rapidly surveil shifts in US overdose mortality. Unprecedented overdose deaths during the pandemic necessitate investments in overdose prevention as an essential aspect of the COVID-19 response and postpandemic recovery. This is particularly urgent for more socioeconomically disadvantaged and racial/ethnic minority communities subjected to the compounded burden of disproportionate COVID-19 mortality and rising overdose deaths.

Going Nowhere: Ambivalence about Drug Treatment during an Overdose Public Health Emergency in Vancouver.

The declaration of an overdose public health emergency in Vancouver has generated an "affective churn" of intervention across youth-focused drug treatment settings, including the expanded provision of opioid agonist therapy. In this article, I track moments when young people became swept up in the momentum of this churn and the future possibilities that treatment seemed to promise. I also track moments when treatment and what happened next engendered a sense of stagnation, arguing that the churn of intervention ensnared many youth in rhythms of starts and stops that generated significant ambivalence toward treatment. The colonial past and present deepened this ambivalence among some Indigenous young people and informed moments of refusal. Youth's lives unfolded through but also around treatment programs, in zones of the city where drug use could generate a sense of momentum that was hooked not on futures, but on the sensorial possibilities of the now. [North America, overdose, drug treatment interventions, youth, affect].

Careful Practices: Ethics and the Anethical in Canadian Addiction Trajectories.

A drug overdose epidemic in North America has sped the expansion of harm reduction services. Drawing on fieldwork in Ottawa, Ontario, we examine forms of care among people offering and accessing these resources. Notably, our interlocutors do not always characterize harm reduction as caring for oneself. Thus, we differentiate between the ethics of care through which one enters desired subject positions, and anethical careful practices. Harm reduction is sometimes anethical, enacted through minor gestures that do not constitute ethical work but allow for its future realization.

Increase in Drug Overdose Deaths Involving Cocaine: United States, 2009-2018.

Deaths from drug overdose continue to contribute to mortality in the United States. The rate of drug overdose deaths involving cocaine has increased in recent years (1-3). This Data Brief provides additional information on drug overdose deaths involving cocaine by examining trends in rates by sex, age group, race and Hispanic origin, and by concurrent involvement of opioids from 2009 through 2018. Rates by urbanicity and census region in 2018 are also examined.

The Relative Economy and Drug Overdose Deaths.

BACKGROUND: Overdose deaths increased exponentially in the United States to be the leading cause of adult injury deaths, and declining economic opportunity may contribute. To our knowledge, there has been no quantitative research into the impact of relative economic measures on overdose risk. Prior longitudinal studies on impact of socioeconomic conditions used fixed effects approaches that can result in biased estimates in the presence of time-varying confounders. METHODS: We estimated county-level longitudinal associations between drug overdose deaths and unemployment and labor-force nonparticipation rates by gender and racial/ethnic subgroup using longitudinal g-computation and the clustered bootstrap. RESULTS: We find evidence for associations between both overall and relative aspects of unemployment and labor-force nonparticipation and drug overdose mortality; patterns of associations differed, sometime qualitatively, across subgroups. For males across racial-ethnic groups, greater overall and relative unemployment rates were generally associated with greater overdose mortality in both the short and long terms [e.g., for white males, increasing the overall percentage of unemployed adults by 5% points in 2000, 2009, and 2015 is associated with an increase of 3.2 overdose deaths (95% confidence interval [CI] = -2.8, 14) in 2015, and increasing the ratio by 0.5 in 2000, 2009, and 2015 is associated with an increase of 9.1 overdose deaths (95% CI = 1.6, 24)]. CONCLUSIONS: These findings point to important complexity in how the economic and contextual landscape differentially shapes overdose risks, underscoring a need for increased understanding of the mechanisms operating for women and minority groups.

Prevalence of and Risk Factors Associated With Nonfatal Overdose Among Veterans Who Have Experienced Homelessness.

Importance: Individuals with a history of homelessness are at increased risk for drug or alcohol overdose, although the proportion who have had recent nonfatal overdose is unknown. Understanding risk factors associated with nonfatal overdose could guide efforts to prevent fatal overdose. Objectives: To determine the prevalence of recent overdose and the individual contributions of drugs and alcohol to overdose and to identify characteristics associated with overdose among veterans who have experienced homelessness. Design, Setting, and Participants: This survey study was conducted from November 15, 2017, to October 1, 2018, via mailed surveys with telephone follow-up for nonrespondents. Eligible participants were selected from the records of 26 US Department of Veterans Affairs medical centers and included veterans who had received primary care at 1 of these Veterans Affairs medical centers and had a history of experiencing homelessness according to administrative data. Preliminary analyses were conducted in October 2018, and final analyses were conducted in January 2020. Main Outcomes and Measures: Self-report of overdose (such that emergent medical care was obtained) in the previous 3 years and substances used during the most recent overdose. All percentages are weighted according to propensity to respond to the survey, modeled from clinical characteristics obtained in electronic health records. Results: A total of 5766 veterans completed the survey (completion rate, 40.2%), and data on overdose were available for 5694 veterans. After adjusting for the propensity to respond to the survey, the mean (SD) age was 56.4 (18.3) years; 5100 veterans (91.6%) were men, 2225 veterans (38.1%) were black, and 2345 veterans (40.7%) were white. A total of 379 veterans (7.4%) reported any overdose during the past 3 years; 228 veterans (4.6%) reported overdose involving drugs, including 83 veterans (1.7%) who reported overdose involving opioids. Overdose involving alcohol was reported by 192 veterans (3.7%). In multivariable analyses, white race (odds ratio, 2.44 [95% CI, 2.00-2.98]), self-reporting a drug problem (odds ratio, 1.66 [95% CI, 1.39-1.98]) or alcohol problem (odds ratio, 2.54 [95% CI, 2.16-2.99]), and having witnessed someone else overdose (odds ratio, 2.34 [95% CI, 1.98-2.76]) were associated with increased risk of overdose. Conclusions and Relevance: These findings suggest that nonfatal overdose is relatively common among veterans who have experienced homelessness. While overdose involving alcohol was more common than any specific drug, 1.7% of veterans reported overdose involving opioids. Improving access to addiction treatment for veterans who are experiencing homelessness or who are recently housed, especially for those who have experienced or witnessed overdose, could help to protect this population.

Drug and Opioid-Involved Overdose Deaths - United States, 2017-2018.

Of the 70,237 drug overdose deaths in the United States in 2017, approximately two thirds (47,600) involved an opioid (1). In recent years, increases in opioid-involved overdose deaths have been driven primarily by deaths involving synthetic opioids other than methadone (hereafter referred to as synthetic opioids) (1). CDC analyzed changes in age-adjusted death rates from 2017 to 2018 involving all opioids and opioid subcategories* by demographic characteristics, county urbanization levels, U.S. Census region, and state. During 2018, a total of 67,367 drug overdose deaths occurred in the United States, a 4.1% decline from 2017; 46,802 (69.5%) involved an opioid (2). From 2017 to 2018, deaths involving all opioids, prescription opioids, and heroin decreased 2%, 13.5%, and 4.1%, respectively. However, deaths involving synthetic opioids increased 10%, likely driven by illicitly manufactured fentanyl (IMF), including fentanyl analogs (1,3). Efforts related to all opioids, particularly deaths involving synthetic opioids, should be strengthened to sustain and accelerate declines in opioid-involved deaths. Comprehensive surveillance and prevention measures are critical to reducing opioid-involved deaths, including continued surveillance of evolving drug use and overdose, polysubstance use, and the changing illicit drug market; naloxone distribution and outreach to groups at risk for IMF exposure; linkage to evidence-based treatment for persons with substance use disorders; and continued partnerships with public safety.