In the Healing Community Study (HCS), we aimed to show that implementation of a battery of evidence-based interventions to expand (1) access to naloxone, (2) the number of patients treated with medications for opioid use disorder (OUD), and (3) safer opioid prescribing practices would result in a 40% reduction of overdose deaths.1 In the HCS, we selected 67 rural and urban communities from four states (Kentucky, Ohio, Massachusetts, and New York), which at the time had some of the highest overdose rates in the country. We randomized communities either to receive the HCS intervention for 18 months or to serve as a control (wave 1), followed by implementation of the HCS intervention for the subsequent 18 months in the control communities (wave 2).2
Communities in partnership with academicians selected the evidence-based interventions and implemented them in collaboration with the health care, 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.3
The article by Larochelle et al.4 is based on the baseline data from the 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 20195 to 108 212 in 2022.6 Larochelle et al. corroborated and brought attention to the marked increases in overdose mortality among Black individuals,4 which continued to contribute to the unprecedented rise in overdose mortality in the subsequent years.7,8
Initially, the opioid overdose crisis most heavily affected non-Hispanic White people primarily because of overprescribing prescription opioid medications. Around 2010 to 2011, the demographics started to shift, coinciding first with a rise in heroin overdoses and subsequently a steep rise in overdoses from illicit fentanyl and its analogs.9 By 2019, it was well established that the main driver of overdose deaths was fentanyl, which accounted for 73% (36 359 of 49 860) of opioid overdose deaths that year.5
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 in the drug supply 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 resources, likely contributed to the rise in overdose mortality first noted in 2018.7
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, or incarceration and had worse outcomes because of inadequate access to quality health care and higher rates of comorbidities.10 Meanwhile, isolation, death of loved ones, loss of jobs, erosion of community support, and rise in homelessness affected individuals of racial/ethnic minority groups especially hard, increasing substance use and relapse for those with substance use disorders, including OUD.
Drug overdose mortality increased 45% over the first years of the pandemic.11 As was the case for COVID-19–related morbidity and mortality, overdose mortality disproportionally affected racial/ethnic minority groups, notably Black individuals and non-Hispanic American Indian and Alaska Native persons. Among Black individuals, the overdose mortality rate per 100 000 rose from 17.1 in 2016 to 24.8 in 20195; then it rose to 47.7 in 2022: a 179% increase from 2016.6 In 2022, non-Hispanic American Indian and Alaska Native people, who were not part of the HCS communities, had the highest overdose mortality rate (64.4 per 100 000)6 across racial/ethnic groups.
The COVID-19 pandemic facilitated changes in the provision of medications for OUD, lowering the requirements for take-home methadone by opioid treatment programs and facilitating the initiation of buprenorphine via telehealth, including from out-of-state providers. The use of telehealth to treat and manage substance use disorders and comorbidities was also accelerated. These changes proved to be lifesaving because they expanded the reach for treating OUD into rural areas, jails, prisons, and harm reduction programs. They increased the number of new initiates into buprenorphine treatment and helped improve retention in treatment during the challenging times of the COVID-19 pandemic.12 Moreover, the findings that the changes in the provision of medications for OUD via telemedicine improved outcomes provided evidence to support their continuation after the termination of the COVID-19 emergency period.12
Since the Larochelle et al. article4 was published, we have learned much both from the HCS and from how communities and providers addressed the challenges of taking care of people suffering from OUD amid the collision of two devastating crises: the COVID-19 pandemic and the overdose crisis (Box 1). The call by Larochelle et al. for targeted interventions to support Black communities was prescient and is as crucial now as it was then if we want to eliminate health inequities and successfully address the overdose crisis.
BOX 1—
Additional Lessons Learned About the Need for Timely Data on Drug Use Patterns and Overdoses to Guide Interventions
| Tailor interventions that are sensitive to demographics |
| Facilitate access to MOUD using diverse settings and models of care |
| Tackle polysubstance use and overdoses |
| Treat and support pregnant women with SUD, including OUD |
| Involve the community in sustaining OUD treatment and recovery |
| Target treatment of OUD among adolescents |
| Use prevention to avert overdoses, including among people with occasional misuse of illicitly manufactured prescription drugs |
Note. MOUD = medications for opioid use disorder; OUD = opioid use disorder; SUD = substance use disorder.
ACKNOWLEDGMENTS
We would like to thank the participating communities, participants, researchers, clinicians, and social service and harm reduction service providers of the Healing Community Study.
Note. The findings and conclusions of this study are those of the authors and do not necessarily reflect the views of the National Institute on Drug Abuse of the National Institutes of Health or the US Department of Health and Human Services.
CONFLICTS OF INTEREST
The authors have no conflicts of interest to disclose.
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