THE OPIOID CRISIS IN THE BLACK COMMUNITY: WHY ARE WE SO SILENT?
A study published Thursday reveals a growing racial disparity in opioid overdose death rates. Deaths among African Americans are growing faster than among whites across the country. The study authors call for an "antiracist public health approach" to address the crisis in Black communities.
The study, conducted in partnership with the National Institute on Drug Abuse at the National Institutes of Health, analyzed overdose data and death certificates from four states: Kentucky, Ohio, Massachusetts and New York. It found that the rate of opioid deaths among Black people increased by 38% from 2018 to 2019, while rates for other racial and ethnic groups did not rise.
The study used data collected before the coronavirus pandemic began; preliminary data show that overall drug overdoses rose in 2020.
In the earlier waves of the opioid crisis, African Americans had lower rates of overdose deaths than whites, according to another study published last year in the journal Addiction, and Black rates stayed level from 1999 through 2012. However by 2013, white rates began to level off while Black rates began increasing.
The new study from NIDA confirms the trend.
"We're seeing the shift in the demographics," says Dr. Nora Volkow, director of NIDA.
Dr. Edwin Chapman, an internal medicine and addiction medicine specialist who serves the African American community in Washington, D.C., says the study is helpful because it shows the serious impact of opioid addiction on Black Americans.
"It points out the fact that we have to do something different, a more intensive intervention in the African-American community," he says.
What's behind the disparity
The shift raises a number of pressing questions about what's driving the growing gap in addiction treatment and prevention and how to close it.
The opioid crisis took off with heavy prescribing of opioid painkillers, primarily in white communities in the 1990s. Volkow says the crisis initially affected white Americans more because they are much more likely to be prescribed opioids than Black people.
"That, in part, reflects on stigmatization against Black people that even if they have pain, physicians are not going to be as receptive to prescribing them opioids," says Volkow.
Structural differences in health care are to blame for racial disparities in addiction treatment as well, says Volkow. These include access to effective evidence-based treatments.
"If you are Black American and you have an opioid use disorder, you are much less likely to be prescribed medications for opioid use disorder," Volkow says, noting that medications like buprenorphine have been known to be very effective in protecting patients from overdosing. "That's discrimination," says Volkow.
The rise of fentanyl, a powerful synthetic opioid that is often laced in heroin, has also affected rates of overdose among Blacks, she says. The main driver of overdose deaths has changed "from prescription opioids then to heroin and now to fentanyl."
Overdose deaths in Black communities are largely caused by fentanyl.
Other factors are at play in these death rates as well, Volkow says. She acknowledges that the federal government and health care systems such as hospitals, community clinics and family doctors need to put in place mechanisms to collect better data. Currently, many physicians don't screen for opioid use disorder, Volkow says.
This data, she says, could "give us a better perspective of the nature of the problem and to help or guide clinicians on interventions."
In the study, the authors noted that in there are also disparities in access to the antidote drug, naloxone, and in training for how to use it to save a life.
Need for true 'public health response'
"It's inner city communities that have been most affected by addiction, where the problem was neglected for four decades," says Dr. Andrew Kolodny, the medical director for opioid policy research at Brandeis University's Heller School for Social Policy and Management. "It wasn't really until we saw a drug crisis affecting white communities that we started to see the resources from Congress."
He says it's important that addiction resources be directed to the communities that need them the most.
"One of the problems here is that we have terrible surveillance of the opioid crisis," Kolodny says. He notes that nationally, data tracking of drug addiction has been patchwork, with some federal agencies focusing on overdose deaths exclusively, others on treatment and others on research. "Surveillance fell through the cracks here," he says.
For COVID-19, the U.S. tracks cases, deaths and hospitalizations at the county level and generally on a daily basis, says Kolodny. "But for the opioid crisis, we don't have a good estimate of how many Americans are opioid-addicted or the communities that are most impacted or incidence rates. We don't know how many people are becoming newly addicted to opioids," says Kolodny. "We are still in the dark ages."
"Opiate addiction is a disease that's preventable and treatable, and you need a public health response that would be similar to even a communicable disease outbreak like COVID."
He says in addition to overdose data by race, the U.S. should track demographics like gender and age and whether those affected live in rural or urban areas. "We need data we can act on. And that's not here," says Kolodny, referring to the new NIDA study, calling it "much too little, much too late."
Improve access to treatment
Addiction specialist Edwin Chapman has made it his life's work to fight the drug epidemic in the Black community. He says that drug addiction in these communities has always been treated differently. "Whether it's racism or cultural incompetence, we need to correct that," he says.
NPR profiled Dr. Chapman's work in 2018 as the opioid crisis began to surge in urban, Black communities across the country.
Chapman knows too well the problems faced by the African American population when it comes to drug addiction and treatment, "beginning with the fact that our epidemic was ignored for the most part, followed by insurance barriers and access to treatment," he says.
"Our population was always treated as a moral, criminal problem, which means that the patients that we're treating in the African American community have that added burden," he says.
From his experience in his clinic, he says he has found it is more complex to treat Black patients, because additional resources, such as help navigating the health care system, counseling and help finding housing or a job, are needed.
Chapman says Black communities also have a "provider access problem." He notes that relatively few addiction treatment specialists focus their practice on treating Black patients. "Then there is the stigma within the provider community about treating these patients because they're always perceived as being criminally inclined or not desirable as a patient," he says.
Conversely, Chapman adds, "there's the shame and stigma that the patients carry, so the patients don't seek treatment."
Chapman says that the number of patients he's treating currently has come down during the pandemic, "some died from COVID, some from overdoses," he says that at the beginning of 2020, his clinic was seeing 270 patients, now the number of patients is 230.
The COVID-19 crisis increased overdose death cases in Washington, D.C., according to the Office of the Chief Medical Examiner. In 2019, which was formerly the highest peak, there were 281 overdose deaths, but 2020 saw around 408, and there have been a total of 157 overdoses this year.
Finding solutions to solve these problems isn't going to be easy, says Chapman. "What we need is what I call a Marshall Plan that is basically a carved-out, taxpayer-funded focus on this subset of high-risk, high-cost patients," he says.
Ignoring the African American population will, in the end, be costlier to the country, he says. It gives him renewed optimism to see new attention on these disparities, and he'll keep treating people and speaking up about how to solve the problem, he says.
Since the late 1990s, deaths from opioid overdoses in the U.S. have climbed relentlessly. In 2019, nearly 50,000 Americans died of an opioid overdose. Drivers of this crisis include prescription opioids, heroin, and fentanyl, a powerful synthetic opioid.
In 2018, NIH launched the Helping to End Addiction Long-term, or NIH HEAL InitiativeSM to help to stem the opioid crisis. As part of that initiative, the HEALing Communities Study (HCS) has been testing prevention and treatment strategies in communities disproportionately affected by opioid overdose deaths.
In a new study, researchers led by Dr. Marc Larochelle from Boston Medical Center and Boston University School of Medicine looked at racial disparities in recent opioid overdose deaths. They focused on four states covered by the HCS: Kentucky, Massachusetts, New York, and Ohio.
The team used state death certificate records from 67 communities to calculate the opioid death rate. They then looked for trends in death rates between 2018 and 2019 based on race or ethnicity. The study was funded in part by NIH’s National Institute on Drug Abuse (NIDA). Results were published on September 9, 2021, in the American Journal of Public Health.
Overall, between 2018 and 2019, the opioid overdose death rate remained relative flat in the communities studied. For both years, it was around 39 deaths per 100,000 residents. But when broken down by race, there were stark disparities.
From 2018 to 2019, the opioid death rate among Black people increased by 38%. These trends varied at the state level. Increases were highest in Kentucky and Ohio.
Opioid overdose death rates didn’t change for Black people in New York between 2018 and 2019. However, they declined by 18% for white people. This suggests that Black people did not benefit equally from prevention and treatment efforts during the years studied.
There are many tools for preventing and treating opioid overdoses. These include overdose education, naloxone distribution, medications to treat opioid use disorder, behavioral therapies, and recovery support services. But these aren’t always deployed in the communities that need them most.
“The more local and timely data communities have access to, the more tailored their approach can be for interventions,” Larochelle explains.
“We must explicitly examine and address how structural racism affects health and leads to drug use and overdose deaths,” says NIDA director Dr. Nora Volkow. “Systemic racism fuels the opioid crisis, just as it contributes mightily to other areas of health disparities and inequity, especially for Black people.”
Non-Hispanic Black individuals in four U.S. states experienced a 38% increase in the rate of opioid overdose deaths from 2018 to 2019, while the rates for other race and ethnicity groups held steady or decreased, according to a new study by the National Institutes of Health published in the American Journal of Public Health. These alarming data are in line with other research documenting a widening of disparities in overdose deaths in Black communities in recent years, largely driven by heroin and illicit fentanyl. The research emphasizes the need for equitable, data-driven, community-based interventions that address these disparities.
The research was conducted as part of the HEALing Communities Study, which aims to significantly reduce opioid-related overdose deaths by helping communities implement evidence-based practices to treat opioid use disorder and reduce other harms associated with opioid use in New York, Massachusetts, Kentucky, and Ohio. It is the largest addiction implementation study ever conducted and is administered in partnership by NIH’s National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration through the Helping to End Addiction Long-term Initiative, or NIH HEAL Initiative.
“We must explicitly examine and address how structural racism affects health and leads to drug use and overdose deaths,” said NIDA Director Nora D. Volkow, M.D. “Systemic racism fuels the opioid crisis, just as it contributes mightily to other areas of health disparities and inequity, especially for Black people. We must ensure that evidence-based interventions, tailored to communities, are able to cut through the economic and social factors that drive disparities in substance use and addiction, to reach all people in need of services.”
For this study, data were collected from death certificates for 2018 and 2019 across 67 communities with a total population of more than 8.3 million people in the four states participating in the HEALing Communities Study. The researchers calculated rates and trends of opioid overdose deaths overall and for each state, and then further analyzed trends by race and ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, other). Overall, the investigators observed no change in the opioid overdose death rate in these states from 2018 (38.3 deaths per 100,000 people) to 2019 (39.5 deaths per 100,000 people).
However, the researchers observed a 38% overall increase in the opioid overdose death rate for non-Hispanic Black individuals from 2018 to 2019, across these four states. There were no changes overall among the other racial and ethnic groups. Trends varied at the state level and increases among non-Hispanic Black individuals were highest in Kentucky (a 46% increase) and Ohio (a 45% increase). The investigators did not observe a significant increase in Massachusetts among non-Hispanic Black individuals. While opioid overdose death rates were unchanged for non-Hispanic Black individuals in New York, there was an 18% decline among non-Hispanic white individuals, suggesting that non-Hispanic Black individuals have not benefitted equally from prevention and treatment efforts.
The study authors note that these data add to the evidence of increasing disparities in opioid overdose deaths by race and ethnicity, and highlight the importance of access to timely, local data to inform effective community-tailored strategies to reduce these deaths. Numerous evidence-based prevention and treatment interventions exist for addressing the opioid overdose crisis, overdose education and naloxone distribution, medications for opioid use disorder, behavioral therapies, and recovery support services. Unfortunately, these interventions have largely failed to gain widespread implementation in community settings including addiction treatment, general medical care, social support services, schools, and the justice system.
To address this challenge, the HEALing Communities Study is working with local, state, and federal partners to gain access to data on opioid-related overdose fatalities, treatment, and other related health concerns in a timelier fashion and include important demographic information including race and ethnicity. Early access to these data was instrumental in informing HEALing Communities Study intervention planning, including discussions ensuring evidence-based practices are equitably available to all racial and ethnic groups. For example, these data informed partnerships with Black community organizations to improve access to overdose education and naloxone distribution.
While the data presented here were critical in shaping public health response, the timeliness of data about drug use, addiction, and overdose is an ongoing challenge. National and state data are typically collected annually, access to the data is limited, and data may not be available for months. Health data related to race and ethnicity may be limited or completely unavailable, and mortality data are particularly lagged due to the time required for toxicology testing.
“The more local and timely data communities have access to, the more tailored their approach can be for interventions,” said lead author Marc Larochelle, M.D., M.P.H., a general internal medicine physician at Boston Medical Center and assistant professor of medicine at Boston University School of Medicine. “We know there are disparities in implementation of effective strategies for reducing opioid overdose deaths, but early access to better data like these allows communities to address equity with improved intentionality.”