Danielle Lehman, BS Jenna Adalbert, MPH Asif Ilyas, MD, MBA, FACS
SUMMARY POINTS:
Prior to the COVID-19 pandemic, approximately 80% of opioid-related deaths have affected White communities relative to all racial communities, with low-income Whites being most vulnerable.
Following the COVID-19 pandemic, the rate of opioid-related overdose deaths has disproportionately affected Black communities.
Future opioid harm reduction interventions should account for the economic impacts of the COVID-19 pandemic on the Black population.
ANALYSIS
Background
Since the 1990s, the “Opioid Epidemic” evolved into one of the most pressing public health issues faced by the United States (U.S.). Since the onset of the crisis, nearly 500,000 deaths have been attributed to opioid overdose, and these deaths have disproportionately affected non-Hispanic White individuals.4
While previous drug epidemics have predominantly affected vulnerable minority populations, the current opioid epidemic has affected predominantly White communities. This disproportionate impact on White communities has been attributed to the higher rate of opioids prescribed to this population (Figure 1).5,11 Social determinant factors, as well as provider bias, may also contribute to this disparity, given that White individuals have greater access and exposure than non-White individuals to opioid prescriptions.6,7 While the dispensing rate of prescription opioids has trended downward in recent years, rates of opioid-related overdose deaths remain tragically high.3 The purpose of this analysis is to explore the effects of racial disparities on the prescription of opioids.
Figure 1. Trend graph depicting opioid overdose deaths by race/ethnicity in the US.8 Retrieved from https://www.kff.org/other/state-indicator/opioid-overdose-deaths-by-raceethnicity/.
Findings
In a population-based study using data collected between 2011-2015 from California’s prescription drug monitoring program, it was found that opioid overdose deaths were concentrated in lower-income, predominantly White communities.6 Results from this study revealed an approximately 10-fold difference in overdose rates amongst the highest proportion of white/lowest-income quintile of zip code tabulation areas compared with the lowest proportion–white/highest-income quintile in California (Figure 2).
Figure 2. Opioid overdose deaths rates per 100,000 people and opioid prescription prevalence amongst individuals aged 15 years and older. Data represent prevalence (across race/ethnicity–income gradient in California) based on the percentage of non-Hispanic white individuals and income disparities in the state of California. Retrieved from Friedman J, Kim D, Schneberk T, et al. Assessment of Racial/Ethnic and Income Disparities in the Prescription of Opioids and Other Controlled Medications in California. JAMA Intern Med. 2019;179(4):469-476.
Additionally, data extracted from the Centers for Disease Control and Prevention’s Multiple Cause of Death database from 1999 to 2017 was used to review opioid-related deaths reported as the leading cause of death. Results indicated that approximately 81% of the 399,230 total opioid-related deaths from 1999 to 2017 were attributed to non-Hispanic Whites, while the remaining 19% of deaths consisted of individuals from all other ethnicities.5 While data from this study has revealed a surge in opioid-related overdose deaths amongst minority populations during this timeframe, it appears that the opioid crisis has overwhelmingly affected the White population.
However, in contrast to the overwhelming number of studies indicating that non-Hispanic White have been predominantly affected by the opioid epidemic, a recent study reviewing racial/ethnic disparities in opioid overdoses during the COVID-19 pandemic in Philadelphia has revealed a dramatic change in the affected population. This study compared fatal and nonfatal opioid-related overdoses before and after the Philadelphia stay-at-home order. Fatal opioid-related overdose (FOO) counts in the 3-month period prior to the stay-at-home order were compared to the FOO counts during the 3-month period after the order in both non-Hispanic White individuals and non-Hispanic Black individuals shown in Figure 3.
Figure 3. Fatal and nonfatal opioid-related overdoses by race/ethnicity from January 2019 through June 2020. Period C represents the period of the stay-at-home order. Retrieved from Khatri UG, Pizzicato LN, Viner K, et al. Racial/Ethnic Disparities in Unintentional Fatal and Nonfatal Emergency Medical Services-Attended Opioid Overdoses During the COVID-19 Pandemic in Philadelphia. JAMA Netw Open. 2021;4(1):e2034878.
Period A represented a 2 month control period in 2019, Period B represented a 2 month period immediately prior to the COVID-19 pandemic, and Period C represented a 2 month period during the “stay-at-home” period during the COVID-19 pandemic. Results from this study revealed a 60.4% increase from Period B to Period C amongst non-Hispanic Black individuals, while a 22.1% decrease was identified amongst non-Hispanic White individuals within this same timeframe.10 While this contradicts previous research regarding racial/ethnic disparities in opioid-related overdoses prior to the COVID-19 pandemic, this finding may be partially attributed to the disproportionate economic fallout experienced by the Black community due to the pandemic. Researchers propose that this population of individuals may be particularly vulnerable to the increasing presence of fentanyl, a synthetic opioid that is more economical, however significantly more potent than other opioids which lead to an increased risk of overdose and death.
Discussion
As our understanding of racial disparities in opioid-related overdose deaths continues to evolve, it is crucial to continue collecting and reviewing data to determine the impact of the pandemic on vulnerable populations at risk for opioid misuse. Additionally, future studies and opioid harm reduction interventions should consider the effects of specific local and broad offending events (such as the COVID-19 pandemic) that may disproportionately affect one racial community over another.9
REFERENCES:
Allen B, Nolan ML, Kunins HV, Paone D. Racial Differences in Opioid Overdose Deaths in New York City, 2017. JAMA Intern Med. 2019;179(4):576-578. doi:10.1001/jamainternmed.2018.7700
Centers for Disease Control and Prevention. 2018. Opioid Overdoses Treated in Emergency Departments. Retrieved May 5, 2021 https://www.cdc.gov/vitalsigns/opioid-overdoses/.
Centers for Disease Control and Prevention. 2018. U.S. Opioid Dispensing Rate Maps. Retrieved May 5, 2021 https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html.
Centers for Disease Control and Prevention. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2015. Available at http://wonder.cdc.gov.
Drake J, Charles C, Bourgeois JW, Daniel ES, Kwende M. Exploring the impact of the opioid epidemic in Black and Hispanic communities in the United States. Drug Science, Policy and Law. January 2020. doi:10.1177/2050324520940428
Friedman J, Kim D, Schneberk T, et al. Assessment of Racial/Ethnic and Income Disparities in the Prescription of Opioids and Other Controlled Medications in California. JAMA Intern Med. 2019;179(4):469-476. doi:10.1001/jamainternmed.2018.6721
Joynt M, Train MK, Robbins BW, Halterman JS, Caiola E, Fortuna RJ. The impact of neighborhood socioeconomic status and race on the prescribing of opioids in emergency departments throughout the United States. J Gen Intern Med. 2013;28(12):1604-1610. doi:10.1007/s11606-013-2516-z
KFF’s State Health Facts. Data Source Centers for Disease Control and Prevention (CDC), National Center for Health Statistics. Multiple Cause of Death 1999-2019 on CDC WONDER Online Database, released 2021. Data are from the Multiple Cause of Death Files, 1999-2019, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program.
Khatri U, Meisel Z, Sun M, Bobyock E, Pizzicato L, South E. Opiate Overdoses Spike in Black Philadelphians, But Drop in White Residents Since COVID-19. Penn Medicine. https://www.pennmedicine.org/news/news-releases/2021/january/opiate-overdoses-spike-in-black-philadelphians-but-drop-in-white-residents-since-covid19. Published 2021 Jan 21.
Khatri UG, Pizzicato LN, Viner K, et al. Racial/Ethnic Disparities in Unintentional Fatal and Nonfatal Emergency Medical Services-Attended Opioid Overdoses During the COVID-19 Pandemic in Philadelphia. JAMA Netw Open. 2021;4(1):e2034878. Published 2021 Jan 4. doi:10.1001/jamanetworkopen.2020.34878
Om, Anjali. The opioid crisis in black and white: the role of race in our nation’s recent drug epidemic. Journal of Public Health. 2018;40(4):614-615. doi:10.1093/pubmed/fdy103
Van Zee A. The promotion and marketing of oxycontin: commercial triumph, public health tragedy. Am J Public Health. 2009;99(2):221-227. doi:10.2105/AJPH.2007.131714