Opioid-related Overdose Deaths Among African Americans: Implications for Research, Practice and Policy

Abstract

Opioid-related overdose deaths among African Americans has only recently received national attention despite evidence of increase in death rates among this population spanning the past decade. Numerous authors have highlighted how the “opioid epidemic” has largely been portrayed as a problem mostly affecting White America. The purpose of this commentary is to provide a synthesis spotlighting the unique structural and cultural considerations involved in research, practice and policy related to opioid use and treatment for opioid use disorders among African Americans. The commentary concludes with considerations for future research and practice intended to reduce deaths among this group.

Only within the past few months has opioid-involved overdose deaths among African Americans received attention as a public health crisis [1]. However, scholars noted this problem several years ago [2–4]. Most studies on opioid use have focused largely on rural and White subgroups [5–11] or focus on racial comparisons using large national datasets. It is likely that nonmedical prescription opioid use and associated health consequences has taken on a different significance and structure within African American communities. Therefore, the purpose of this paper is to spotlight the multifaceted issues affecting opioid use and treatment for opioid use disorders among African Americans specifically noting considerations for research, practice and policy.

Substantial Increase in Opioid Use among African Americans

From 2015 to 2017 African Americans in metro areas experienced the largest absolute and percentage increases in drug overdose deaths from opioids when compared with other race/ethnicities. Specifically, death rates involving any opioid increased 103% [from 11.8 to 24.0 per 100,000) and deaths involving synthetic opioids increased 361% (from 3.6 to 16.6 per 100,000) [1]. Fatal outcomes have also disproportionally affected African Americans as a result of mixing opioids with illicit drugs, and other classes of prescription drugs [4]. African American drug users report using prescription drugs to enhance or moderate the effects of other drugs, for example to “come down” or to accentuate the “high” [12]. For example, when asked specifically about codeine use, a participant stated, “the high last longer when you smoke weed and take syrup. It’s even better if you can get a Xanax or a Tylenol 3”[13]. This quote speaks directly to the danger of mixing opioids with other prescription or illicit drugs increasing risk for overdose. Nationally, from 2014–2015 prescription opioid deaths in combination with heroin and cocaine were the most prevalent among African Americans when compared to other races [4]. Urban African Americans are more likely to receive illicit drugs from dealers when compared to rural African Americans, resulting in an increased probability that the drug may be adulterated with fentanyl [14]. Understanding the impact of opioids use among African Americans is complex and involves consideration of polysubstance use.

Nonmedical prescription opioid use is associated with an increased risk for heroin use, [15, 16] but this trajectory is unclear when it comes to understanding patterns among African Americans [16]. Evidence suggests the intranasal heroin use and use of prescription opioid pills are more prevalent among African Americans when compared to Whites [17]. Further, African Americans have the lowest injection drug use rates when compared to Whites and Latinos [17]. These data may contribute to a lower perception of risk and associated health disparities resulting in less attention to the opioid epidemic among this population. Consequently, despite trends [18] resulting in an increase in mortality and morbidity, researchers have focused on the “opioid crisis” in the United States as largely a problem among White Americans,[2, 19] [3, 20] neglecting the unique impact of nonmedical prescription opioid use among African Americans.

Limitations of Current Studies on Opioid Use Among African Americans

Large national datasets are limited in scope because they do not include culturally-relevant factors that affect the day-to-day lives of many African Americans. In addition, national datasets are limited to community-based samples. African Americans are disproportionately impacted by structural factors such as incarceration [21]. However, national surveys may not accurately capture data on individuals that cycle in and out of correctional facilities [22]. Notably, overdose is a leading cause of death among prisoners returning to the community [23, 24]. Specific to overdose prevention, although some states may have the “Good Samaritan law” protecting individuals from prosecution that report an overdose, African Americans may be less likely to call 911 or law enforcement in a drug-related emergency, particularly if they have had prior legal problems [25, 26]. Relying on national datasets may result in lower prevalence estimates and could be a missed opportunity to gather information from individuals at highest risk for overdose due to criminal justice involvement and incarceration.

Cultural factors such as chronic discrimination [27, 28] may also influence patterns of nonmedical prescription opioid use. African Americans are less likely to be prescribed opioid analgesics for severe pain when compared to White patients with similar presenting problems [29–31]. There is evidence that racial bias and false biological beliefs about African Americans (e.g., “Blacks’ skin is thicker than Whites”[32]) among White health care providers significantly impact the assessment of pain and prescribing practices of opioids to African Americans [32–34]. These culturally unique and negative experiences with health providers [35] may drive some African Americans to seek prescription opioids by way of diversion, sharing medicine and obtaining prescription drugs from family or friends [36, 37]. Given the limitations of national data, we know little about how unique structural or cultural factors may be associated with nonmedical prescription opioid use and related health risk among African Americans.

Challenges Associated with Treatment for Opioid Use Disorders

African Americans are less likely to receive medications for opioid use disorders [38]. Notably, African American opioid users have the lowest treatment completion rates when compared to other races/ethnicities [39, 40]. Barriers to medications for opioid use disorders for many African Americans include lack of insurance, transportation, and childcare. However, while the use of peer outreach [41] and mobile treatment [42] have demonstrated improvement in access to treatment among some African Americans, other studies show persistent cultural barriers and beliefs such as a general mistrust of methadone and needle/syringe exchange programs [43]. For example, some African Americans believe White community outsiders were “experimenting” on them and that these programs served to locate and potentially isolate opioid dependent African Americans in their own communities [43]. Further, evidence suggests negative stigma associated with methadone treatment when compared to buprenorphine,[44] however buprenorphine treatment had lower early retention rates when compared to methadone treatment among African Americans [45]. Among those seeking methadone treatment, there is evidence that providers significantly under-dose African American patients nationwide in private and public agencies [46]. In addition, historically buprenorphine was not available to individuals that did not have private insurance or a private physician limiting access to many African Americans who were opioid dependent [47]. Despite the adoption of buprenorphine in public-sector treatment agencies, the availability in largely segregated African American neighborhoods continues to be a barrier for treatment [48]. The opioid crisis is affecting African American communities and the needed response complex due to unique structural and cultural issues that are often omitted in research.

Research, Policy and Practice Considerations

Literature on nonmedical prescription opioid use has largely relied on national datasets and focused on examining racial differences [49–54]. Subsequently, results are limited in depth regarding understanding findings specific to subgroups and conclusions may lack relevance or context for marginalized groups. A consideration for research and practice is that participants may not recognize the pharmaceutical names for opioids or other prescription drugs. For example, in a pilot with African America men study Wheeler and colleagues modified the drug questions in the Addiction Severity Index-Version V (ASI-V) [55] to include more culturally-relevant terms during data collection [56]. Participants were asked: Have you ever used opiates not prescribed to you? For example, suboxone, “subs,” “Hospital Heroin/Dilaudid,” “oxy,” “percs/percocet,” “norco,” “blue pills,” “vikes/vicodin/hydrocodone,” or “OCs”. While it is likely street names may vary by geography, the authors concluded that the inclusion of street name or slang terms for prescription drugs in research and assessment could yield more accurate data among African Americans [56]. Modifying language in survey data is a single consideration. Additional research efforts specific to prevention and tailored interventions include testing public health messages that are culturally relevant, minimizes stigma associated with drug use and treatment and use language that is accessible to the targeted audience [1, 57, 58].

Another significant need for research is to specifically target African Americans with histories of cocaine and heroin use in the wake of increased overdose deaths associated with fentanyl. The use of rapid fentanyl test strips has been proven to be a promising harm reduction approach to overdose prevention [59, 60]. Yet studies to date have consisted of small samples and limited to young adults. Given the significant risk of overdose among older African Americans [1] and those newly re-entering the community from prison or jail with prior histories of cocaine and heroin use [61], targeting these vulnerable populations for clinical research with fentanyl test strips could have a substantial impact on overdose prevention.

A direct policy and practice implication would be to increase access to naloxone in African American communities. African Americans are more likely to be criminalized for drug use [2, 3, 19] and therefore may be less likely to approach law enforcement officers or first responders to request naloxone [26]. Therefore, increasing the availability of naloxone through distribution when a person is released from jail or prison [62–64] coupled with targeting African American communities for naloxone education [65] could also reduce the increasing death rates among this group.

Lastly, there is a significant need for improvement within the medical community surrounding opioid use and African Americans. The issue of racism and bias needs to be addressed among medical providers to reduce instances of discriminatory practices in prescribing opioids for the treatment of pain among African Americans. Responsible treatment with the use of opioids could reduce the need for diversion [36, 37] of medication and use outside of medical supervision. Further, when African American patients present with a possible opioid use disorder, providing proper education, referrals and treatment is essential. There may be misconceptions in the African American community surrounding how an opioid use disorder affects the physiology of the brain and results in physiological dependence. Therefore, treatment with medications for opioid use disorders may be seen negatively as substituting one drug for another as opposed to a necessary part of recovery [43, 66]. Providing education surrounding opioid use disorders and evidence-based treatment options coupled with treatment providers issuing culturally competent care (e.g., ceasing underdosing practices) could have long-term and sustainable outcomes for this community.

Conclusion

In December 2017, the Advisory Committee on Minority Health recommended the need to focus African Americans and to promote research that will impact culturally-informed treatment in order to prevent opioid use disorder and overdose [67]. Given overdose rates among African Americans has risen exponentially over the past decade, [1, 68] progress targeting this group has been slow moving. A multidisciplinary approach is needed to directly address the multifaceted and unique structural and cultural factors that will reduce deaths among this underserved group.