EDITORIAL: APH Disparities in Overdose Deaths: Looking Back at Larochelle and Colleagues’ 2021 Paper

By Nora D. Volkow, MD, Beth Han, PhD, MD, MPH, and Redonna K Chandler, PhD

About the Authors:

All authors are with the National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD.

The opioid overdose crisis, initially most heavily affecting non-Hispanic White people primarily due to overprescribing prescription opioid medications, began shifting demographics around 2010 to 2011. This change coincided first with a rise in heroin overdoses and subsequently a steep rise in overdoses from illicit fentanyl and its analogs. By 2019, it was well established that the main driver of overdose deaths was fentanyl, accounting for 36,359 of the 49,860 opioid overdose deaths that year.

However, it was difficult to predict how rapidly fentanyl would take over the illicit drug market across the United States and contaminate the drug supply, including that of heroin, stimulant drugs, and counterfeit pills. This shift exposed individuals who did not use opioids, and hence had no tolerance to them, to overdoses when they consumed contaminated products. Even for people with histories of heroin use, the much greater potency of fentanyl increased overdose risk. Contamination of cocaine and heroin used by Black individuals, coupled with racial/ethnic inequity in opioid prevention, intervention, and treatment capabilities, community support organizations, and other resources, likely contributed to the rise in overdose mortality first noted in 2018.

The article by Larochelle et al. is based on the baseline data from four states that were part of the HCS. Larochelle et al. reported that from 2018 to 2019, the overdose deaths appeared to have stabilized except among non-Hispanic Black individuals (hereafter Black individuals), for whom overdose deaths increased by nearly 40%. We did not know then that the period of stabilization observed during 2018 to 2019 (except for Black individuals) would be so short-lived, nor did we imagine that four years later the overdose deaths would increase 53% from 70,630 in 2019 to 108,212 in 2022.

Another major event that could not have been predicted at the time the Larochelle et al. article was written was the COVID-19 pandemic. The pandemic disrupted the lives of communities and was exacerbated among people who use drugs, including those with an OUD. The COVID-19 pandemic affected all demographics but was particularly catastrophic among racial/ethnic minority groups, most notably Black individuals and Hispanics. From the beginning, clear disparities emerged in COVID-19-related morbidity and mortality for communities of color. These communities were at higher risk of infection owing to hazardous labor-related exposures, living conditions, and limited access to health services.

Communities in partnership with academicians selected the evidence-based interventions and implemented them in collaboration with the healthcare, behavioral health, and justice systems, as well as state agencies, while monitoring progress using data indicators. This first step required that the communities obtain baseline data on demographics, overdose mortality, treatment capabilities, community support organizations, and other resources, and implement a battery of evidence-based interventions to expand access to naloxone, increase the number of patients treated with medications for opioid use disorder (OUD), and promote safer opioid prescribing practices. The expected result was a 40% reduction in overdose deaths.