ROMINA GARAKANI, BS
ASIF ILYAS, MD, MBA, FACS
Opioid death rates have increased among Black Americans.
Non-White people who inject drugs face a gap in naloxone training compared to White people who inject drugs.
Racial inequities exist in access, training, and use of naloxone.
The opioid epidemic is a serious public health crisis in the United States. Between 1999 and 2019, about 500,000 people died from an overdose involving both prescription and illicit opioids . According to a 2019 National Survey on Drug Use and Health, 10.1 million people misused prescription opioids and 1.6 million people had an opioid use disorder in that year alone . In 2017, the U.S. Department of Health and Human Services (HHS) declared a public health emergency. With this declaration, the HHS implemented a “5-Point Strategy to Combat the Opioid Crisis”, which included: strengthening public health surveillance, improving pain management, improving access to treatment, prevention, and recovery services, support of research efforts involving opioids and pain, and increasing the availability of overdose-reversing drugs [2,3].
The most common overdose-reversing drug that has become increasingly accessible outside to the public is naloxone. Naloxone is a competitive opioid antagonist that has a high affinity for the mu-opioid receptor. Naloxone can be used for accidental or intentional overdoses as well as for acute or chronic toxicity. In the case of an overdose, reversal is seen in most cases within a few minutes .
Efforts have been made to increase the availability of naloxone outside of the hospital setting, such as intranasal dose formulations now available to the public in many areas across the country. Though such expansions are being made, in recent years, opioid death rates have accelerated among Black Americans . In fact, Black men are the demographic with the largest increase in death rates, having tripled between 2015 and 2020 (Figure 1a) . Potential factors for such findings may be differences in education, access, and use of naloxone. The goal of this analysis is to investigate whether racial disparities exist in access to naloxone.
Figure 1 a) Drug Overdose Death Rates by Race and Ethnicity Among Men between 2015 and 2020 b) Drug Overdose Death Rates by Race and Ethnicity Among Women Between 2015 and 2020. Reprinted from Gramlich, John. Recent Surge in U.S. Drug Overdose Deaths Has Hit Black Men the Hardest. January 19, 2022. Pew Research Center. Accessed June 28, 2022. https://www.pewresearch.org/fact-tank/2022/01/19/recent-surge-in-u-s-drug-overdose-deaths-has-hit-black-men-the-hardest/
A cross-sectional study examined the naloxone delivery cascade among people who injected drugs (PWID) in Los Angeles, CA, and San Francisco, CA . Researchers developed and assessed naloxone engagement and re-engagement cascades to understand where access drops off, and to identify where disparities in the cascade exist. As seen in the naloxone engagement cascade (Figure 2a) PWID that identified as White had the highest percentage of ever receiving naloxone, receiving naloxone in the past 6 months, and currently owning naloxone, while Latinx and Black PWID had the lowest percentages. The study found statistically significant differences when comparing race/ethnicity in ever receiving and receiving naloxone in the past six months. Additionally, the study found no significant difference across races and ethnicities in the percentage of PWID who used and/or lost naloxone or received a naloxone refill in the past six months (Figure 2b) .
Figure 2 a) Naloxone Engagement Cascade Among PWID by Race/Ethnicity b) Naloxone Re-Engagement Cascade by Race/Ethnicity. Reprinted from Kinnard EN, Bluthenthal RN, Kral AH, Wenger LD, Lambdin BH. The naloxone delivery cascade: Identifying disparities in access to naloxone among people who inject drugs in Los Angeles and San Francisco, CA. Drug and alcohol dependence. 2021;225:108759-108759.doi:10.1016/j.drugalcdep.2021.1087 59
Another study in 2018 focused in on San Francisco, CA, which has one of the largest naloxone distribution and administration training programs, and analyzed survey data of PWID and found that non-White PWID was significantly less likely to receive training than White PWID . Similarly, another study focused on Baltimore, MD, a city with some of the highest reported urban opioid overdose rates in the country, identified significant racial inequalities in engagement in overdose prevention . Of the 16 participants who had not heard of naloxone, 94% were Black PWID. White PWID had significantly higher rates of naloxone access, training, and use compared to Black PWID . Though Baltimore has existing public health interventions to ensure widespread distribution of naloxone, the persistent disparities emphasize the influence of racial inequities when planning and administrating public health naloxone programs.
As public health interventions and programs are being implemented to promote awareness and use of naloxone, it is important to continue assessing whether gaps exist in the accessibility of overdose-reversing drugs. Current studies have determined that a racial disparity gap does in fact exist in naloxone training, access, and use. Future studies should focus efforts on expanding the assessment to other regions in the United States to obtain more generalizable findings. Future research could include investigating and implementing methods that would close gaps in access to naloxone.
Drug Overdose. Centers for Disease Control and Prevention. Updated March 17, 2021. Accessed June 21, 2022. https://www.cdc.gov/drugoverdose/epidemic/index.html
About the Epidemic. U.S. Department of Health and Human Services. Updated October 27, 2021. Accessed June 21, 2022. https://www.hhs.gov/opioids/about-the-epidemic/index.html
Decrease Opioid Misuse. Alliant Health Solutions. 2020. Accessed June 22, 2022. https://quality.allianthealth.org/topic/decrease-opioid-misuse/#:~:text=To%20combat%20the%20ongoing%20opioid,drugs%205)%20Supporting%20cutting-edge
Jordan MR, Morrisonponce D. Naloxone. [Updated 2021 Jul 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441910/
Kinnard EN, Bluthenthal RN, Kral AH, Wenger LD, Lambdin BH. The naloxone delivery cascade: Identifying disparities in access to naloxone among people who inject drugs in Los Angeles and San Francisco, CA. Drug and alcohol dependence. 2021;225:108759-108759. doi:10.1016/j.drugalcdep.2021.108759
Gramlich, John. Recent Surge in U.S. Drug Overdose Deaths Has Hit Black Men the Hardest. January 19, 2022. Pew Research Center. Accessed June 28, 2022. https://www.pewresearch.org/fact-tank/2022/01/19/recent-surge-in-u-s-drug-overdose-deaths-has-hit-black-men-the-hardest/
Kim K, Oh H, Miller D, Veloso D, Lin J, McFarland W. Prevalence and disparities in opioid overdose response training among people who inject drugs, San Francisco: Naloxone training among injectors in San Francisco. The International Journal of Drug Policy. 2021;90:102778-102778. doi:10.1016/j.drugpo.2020.102778
Dayton L, Tobin K, Falade-Nwulia O, et al. Racial Disparities in Overdose Prevention among People Who Inject Drugs. Journal of urban health. 2020;97(6):823-830. doi:10.1007/s11524-020-00439-5