Drug overdose mortality among stateside Puerto Ricans: Evidence of a health disparity

MOUD use among Hispanic clients increased post-ACA, yet differed by heritage and geographic location

BACKGROUND

Overdose death rates for Hispanic people rose 2010-2022. Opioid overdose rates grew faster among Hispanic people than non-Hispanic White people ("White"). Medication for opioid use disorder (MOUD) is an effective but underutilized intervention for decreasing overdose risk. The Affordable Care Act ("ACA") should have increased MOUD use, but insurance and behavioral health reforms differed by state. We examined to what extent MOUD use increased post-ACA implementation and differed for Hispanic people (overall and by heritage group) compared to White people who used opioids ("clients").

METHODS

We analyzed first annual ambulatory care episodes (TEDS-A, 2009-2019) for working-age Hispanic (N= 76,591) and White (N=444,753) clients. We categorized Hispanic clients by heritage group (Puerto Rican, Mexican, or Other Hispanic). We grouped states by Medicaid expansion status (California, Other Expansion States, and Non-Expansion States). We used logistic regression to compare the odds of MOUD use pre/post ACA within racial/heritage groups, and, separately, between racial/heritage groups using pre-ACA White clients as a reference group. We used linear probability difference-in-differences to confirm changes in MOUD use between Hispanic and White clients.

RESULTS

Among Hispanic clients in ambulatory care, MOUD use was lowest in the Non-Expansion States and highest in California. Nationally, only Puerto Rican and Other Hispanic heritage clients had higher odds of MOUD post-ACA compared to pre-ACA. Nationally and in Other Expansion States, Hispanic and White clients had similar increases in MOUD use post-ACA.

CONCLUSIONS

MOUD use among Hispanic clients rose post-ACA, but differences remained between Hispanic heritage groups and between states.

Racial/ethnic inequality in homelessness and drug overdose deaths in US States

PURPOSE

This study examined whether state-level racial disproportionality in homelessness is associated with racial disproportionality in overdose mortality.

METHODS

Counts of individuals experiencing homelessness (2015-2017; by state and racial/ethnic group) were obtained from the US Department of Housing and Urban Development; population estimates and counts of drug overdose deaths (2018-2021; by state and racial/ethnic group) were obtained from the National Center for Health Statistics. Homelessness and overdose mortality disproportionality scores were calculated to indicate the extent to which each racial group was over- or under- represented among those experiencing homelessness, or among overdose deaths, respectively (relative to each racial group's proportional share in the general population). For each racial group examined, ordinary least squares regression models with robust standard errors (SEs) examined associations between state-level disproportionality in homelessness and disproportionality in overdose mortality, adjusting for percent aged 18-64 and US Census Region, as well as disproportionality in educational attainment and unemployment.

RESULTS

State-level racial disproportionality in homelessness was significantly and positively associated with racial disproportionality in overdose mortality for Black (b = 0.16 [SE = 0.05]; p < .01), American Indian/Alaska Native (b = 0.71 [SE = 0.23]; p < .01), and Hispanic populations (b = 0.17 [SE = 0.05]; p < .01), in models adjusting for region and percent aged 18-64. The significant positive associations in these three populations persisted after adjusting for educational attainment disproportionality, yet the association was no longer significant in the Black population after adjusting for unemployment disproportionality.

CONCLUSION

States with the highest levels of racial/ethnic minority overrepresentation in homelessness generally also had relatively higher levels of racial/ethnic minority overrepresentation in overdose deaths.

Impact of neighborhood-level COVID-19 mortality on the increase in drug overdose mortality in New York City during the COVID-19 pandemic

BACKGROUND

Overdose mortality increased substantially during the COVID-19 pandemic, but it is unclear to what extent the COVID-19 mortality had contributed to this increase at the neighborhood level.

METHODS

This was an ecological study based on New York City United Hospital Fund (NYC UHF) neighborhood-level data from 2019 to 2021, split into two time-windows: pre-COVID (2019) and during-COVID (2020 and 2021). Linear regression models were used to estimate the effect of cumulative COVID-19 mortality on the increase in drug overdose mortality from the pre-COVD to during-COVID periods at the neighborhood level, with and without adjusting for neighborhood characteristics.

RESULTS

Drug overdose mortality rate increased from 21.3 to 33.4 deaths per 100,000 person-years across NYC UHF neighborhoods from pre-COVID to during-COVID. For each additional COVID-19 death per 1,000 person-years at the neighborhood level, the increase in drug overdose mortality rose 2.4 (95% CI: 1.7, 3.3) times. Furthermore, neighborhoods with a higher percentage of Hispanic residents, a higher percentage of single-person households, and a higher percentage of residents with health insurance experienced significantly larger increases in drug overdose mortality. In contrast, neighborhoods with a higher percentage of residents aged 75 and older had a smaller increase in drug overdose mortality.

CONCLUSIONS

NYC neighborhoods with higher cumulative COVID-19 mortality experienced a greater increase in drug overdose mortality during the first two years of the COVID-19 pandemic.

"It didn't hurt me": patients' and providers' perspectives on unsupervised take-home doses, drug diversion, and overdose risks in the provision of medication for opioid use disorder during COVID-19 in San Juan, Puerto Rico

BACKGROUND

During the COVID-19 pandemic, clinics offering medication for opioid use disorder (MOUD) needed to rapidly introduce unsupervised take-home dosing, while relapsing patients and patients unable to enter treatment faced increased risks of fentanyl-related overdose deaths and other drug-related harms. Based on a qualitative study of people who inject drugs (PWID) receiving MOUD treatment and MOUD staff in Puerto Rico, this paper documents the lived experiences of patients and providers during this period and the risk perceptions and management strategies to address substance misuse and drug diversion attributable to unsupervised take-home-dose delivery.

METHODS

In-depth qualitative interviews were conducted with patients (N = 25) and staff (N = 25) in two clinics providing MOUD in San Juan, Puerto Rico, during 2022. Patients and staff were receiving or providing treatment during the pandemic, and patients reported injection drug use during the past thirty days.

RESULTS

Patients were overwhelmingly male (84%), unmarried (72%), and unemployed (52%), with almost half (44%) injecting one to three times a day. Mean time in treatment was 7 years. Staff had a mean age of 46 years with more than half of the sample (63%) female. The majority of patients believed that unsupervised take-home dosing had no significant effect on their treatment adherence or engagement. In contrast, providers expressed concerns over the potential for drug diversion and possible increased risks of patient attrition, overdose episodes, and poor treatment outcomes.

CONCLUSION

This study underscores the importance of insider perspectives on harm-reduction changes in policy implemented during a health crisis. Of note is the finding that staff disagreed among themselves regarding the potential harms of diversion and changes in drug testing protocols. These different perspectives are important to address so that future pandemic policies are successfully designed and implemented. Our study also illuminates disagreement in risk assessments between patients and providers. This suggests that preparation for emergency treatment plans requires enhanced communication with patients to match treatments to the context of lived experience.

Overdose deaths involving synthetic opioids: Racial/ethnic and educational disparities in the eastern and western US

BACKGROUND

This study examined racial/ethnic and educational disparities in US synthetic opioid overdose mortality East and West of the Mississippi River.

METHODS

Using restricted-access 2018-2021 mortality data from the Centers for Disease Control and Prevention and population estimates from the American Community Survey, age-standardized rate ratios (SRRs) and 95% Confidence Intervals (CIs) were used to compare rates of synthetic opioid mortality by race/ethnicity and educational attainment level in the regions East and West of the Mississippi River.

RESULTS

Racial/ethnic disparities in synthetic opioid mortality rates, relative to the Non-Hispanic (NH) White population, were observed in the NH Black (SRR, 1.5 [95% CI, 1.5-1.6]) and NH American Indian/Alaska Native (SRR, 2.1 [95% CI, 1.9-2.2]) populations in the West, and the Puerto Rican (SRR, 1.3 [95% CI, 1.3-1.3]) and NH American Indian/Alaska Native (SRR, 1.5 [95% CI, 1.4-1.6]) populations in the East. Relative to those with a Bachelor's degree or higher: in the West, the synthetic opioid mortality rate was more than seven times as high for those with a high school diploma only (SRR 7.7 [95% CI, 7.4-8.0]), and in the East, approximately thirteen times as high for those with a high school diploma only (SRR, 13.0 [95% CI, 12.7-13.3]) or less than a high school diploma (SRR, 13.3 [95% CI, 13.0-13.7]).

CONCLUSION

Disparities in rates of synthetic opioid mortality differ in the eastern and western US, supporting tailored responses within each region.

"I don't want to die": a qualitative study of coping strategies to prevent fentanyl-related overdose deaths among people who inject drugs and its implications for harm reduction policies

BACKGROUND

Fentanyl and fentanyl-related analogues are the main drivers of overdose death in the USA, particularly among people who inject drugs (PWID). Despite the fact that non-Hispanic whites exhibit higher population rates of synthetic opioid mortality, overdose deaths have increased among African American and Latinos in urban areas. Yet little attention has been paid to the introduction of fentanyl among rural PWID in Puerto Rico.

METHODS

We conducted N = 38 in-depth interviews with PWID in rural Puerto Rico to document participants' experiences of injection drug use after the arrival of fentanyl and the strategies they implemented to manage overdose death risks.

RESULTS

Participants suggest that the arrival of fentanyl in large scale happened after Hurricane Maria in 2017; this coincided with a dramatic increase in overdose episodes and deaths. Fear of overdose deaths motivated some participants to substitute intravenous drug use for other forms of substance use or to seek MOUD. PWID that continued injection use resorted to conducting "hit tests," avoiding injecting alone, using naloxone, and employing fentanyl testing strips.

CONCLUSIONS

While overdose deaths would have been higher without participants' willingness to adopt harm-reduction strategies, this paper illustrates the limits of these policies to address the current epidemic of fentanyl-related overdose deaths among this population. More studies are needed to understand how health disparities shape overdose risks for minority populations. However, major policy changes, in particular the revision of the harmful role of the War on Drugs and the termination of failed neoliberal economic policies that contribute to deaths of despair, should be addressed if we are to make a dent in this epidemic.

Opioid-related mortality: Dynamic temporal and spatial trends by drug type and demographic subpopulations, Massachusetts, 2005-2021

BACKGROUND

Fatal opioid-related overdoses (OOD) present significant public health challenges. Intuitive and replicable analytical approaches are needed to inform targeted public health responses.

METHODS

We obtained fatal OOD data for 2005-2021 from the Massachusetts Registry of Vital Records and Statistics. We conducted heatmap analyses to assess trends in fatal OOD rates per 100,000 residents, visualizing rates by death year and decedent age at one-year intervals, stratifying by race/ethnicity, sex, rurality, and involved substances. We calculated Getis-Ord Gi* statistics to identify spatial clusters of OOD rates.

RESULTS

Among 20,774 fatal OODs, rates were higher among males, and highly variable by race/ethnicity, age group, and rurality. While fatal OOD rates increased in urban before rural communities, rates were higher in rural communities by 2018-2019. Stimulant-related fatal OODs were elevated in 2020 and 2021. Fatal OOD rates involving fentanyl and stimulants increased precipitously and simultaneously in the non-Hispanic Black population in 2020 and 2021, with a bimodal age distribution peaking among those in their 40s and 60s. Elevated rates among 30-to-60 year old Hispanic residents were largely tied to synthetic opioids from 2015 to 2021. Spatial clusters were detected for prescription opioids, heroin, and stimulants in western Massachusetts. For synthetic opioids, hotspots became more ubiquitous across the state from 2016 to 2021, intensifying in southeastern Massachusetts.

CONCLUSION

Our novel approach uncovered new time varying and spatial patterns in fatal OOD rates not previously reported. Identified shifts in fatal OOD rates by sex, age, and race/ethnicity can inform location-specific field actions targeting subpopulations at disproportionally high risk.

Similarities and Differences in Alcohol & Other Drug Dependence Among Hispanic/Latino Subgroups: A Disaggregation Approach

Background

Hispanic/Latino (H/L) heritage civilians out-number all other non-White ethnic groups in the United States. When studied as one group, H/L diversity is ignored, including rates of drug misuse. This study's aim was to examine H/L diversity regarding drug dependence by disaggregating how the burdens of active alcohol or other drug dependence (AODD) might change if we were to address syndromes drug by drug.

Method

Studying non-institutionalized H/L residents from the National Surveys on Drug Use and Health (NSDUH) 2002-2013 probability samples, we utilized online Restricted-use Data Analysis System variables to identify ethnic heritage subgroups and active AODD via computerized self-interviews. We estimated case counts of AODD with analysis-weighted cross-tabulations and variances from Taylor series. Radar plots disclose AODD variations when we simulate the reductions of drug-specific AODD one by one.

Results

For all H/L heritage subgroups, the most substantial AODD decline might be achieved by reducing active alcohol dependence syndromes, followed by declines of cannabis dependence. The burdens due to active syndromes attributed to cocaine and pain relievers vary somewhat across subgroups. For the Puerto Rican subgroup, our estimates reveal potentially important burden reduction if active heroin dependence can be decreased.

Conclusion

A sizeable reduction in the H/L population health burden attributable to AODD syndromes might be achieved via the effective decline of alcohol and cannabis dependence among all subgroups. Future research includes a systematic replication with recent NSDUH survey data, as well as various stratifications. If replicated, the need for targeted drug-specific interventions among H/L will become unequivocal.

Substance use, injection risk behaviors, and fentanyl-related overdose risk among a sample of PWID post-Hurricane Maria

BACKGROUND

While natural disasters like hurricanes are increasingly common, their long-term effects on people who inject drugs are not well understood. Although brief in duration, natural disasters can radically transform risk environments, increasing substance use and drug-related harms.

METHODS

Based on a study of people who inject drugs (PWID) and injection risk behaviors in rural Puerto Rico, the present study uses data from two different phases of the parent study. Data for 110 participants were collected from December 2015 to January 2017, soon before Hurricane Maria landed in September 2017; the 2019 phase, in the aftermath of the hurricane, included a total of 103 participants. The present study's main analyses used data from 66 PWID who participated in both the pre-Maria and post-Maria interviews (66 individuals measured at two time points, for a total of 132 observations), using mixed-effects binomial logistic regression to examine recent overdose experiences pre- and post-Maria. A separate descriptive analysis included all 103 participants from the 2019 interview.

RESULTS

After Hurricane Maria, some declines in injection frequency were observed (the percentage of people reporting injecting monthly or less increased from 3.0% before Hurricane Maria to 22.7% after Hurricane Maria). However, fewer PWID reported using a new needle for most or all injections. In the pre-Maria interview, 10.6% of participants indicated they had experienced an overdose during the year of the interview and/or the calendar year prior, and this figure increased to 24.2% in the post-Maria interview. In the regression analysis, the odds of reporting an overdose during the interview year and/or calendar year prior were three times as high post-Maria, relative to pre-Maria (odds ratio 3.25, 95% confidence interval 1.06-9.97).

CONCLUSION

Substance use patterns, injection risk behaviors, and overdose episodes and deaths differed after Hurricane Maria, relative to before the hurricane, yet it is unclear to what extent these changes also reflect the simultaneous arrival of fentanyl. In preparation for future natural disasters, it is imperative to strengthen the health infrastructure by enhancing access and curbing barriers to syringe services programs and medications for opioid use disorder, particularly in rural or underserved locations.

Relationships between places of residence, injury, and death: Spatial and statistical analysis of fatal opioid overdoses across Massachusetts

Understanding the factors associated with where people who use opioids live, where their fatal overdoses occur, and where deaths are recorded can improve our knowledge of local risk environments and inform intervention planning. Through geospatial analyses of death certificate data between 2015 and 2017, we found that a majority of opioid-involved fatal overdoses in Massachusetts occurred at home. Age (adjusted odds ratio [AOR], 1.03; 95% confidence interval [CI], 1.02-1.04), living in a census tract with a higher percentage of crowded households (AOR, 1.04; 95% CI, 1.01-1.08), households without vehicles (AOR, 1.01; 95% CI, 1.00-1.02), and Hispanic ethnicity (AOR, 0.56; 95% CI, 0.42-0.74) were independently associated with fatal overdose at home. Using geographically weighted regression, we identified locations where these associations were stronger and could benefit most from home-based and culturally sensitive overdose prevention efforts, including expanded overdose education and naloxone distribution.

Toward a Theory of the Underpinnings and Vulnerabilities of Structural Racism: Looking Upstream from Disease Inequities among People Who Use Drugs

Structural racism is increasingly recognized as a key driver of health inequities and other adverse outcomes. This paper focuses on structural racism as an "upstream" institutionalized process, how it creates health inequities and how structural racism persists in spite of generations of efforts to end it. So far, "downstream" efforts to reduce these health inequities have had little success in eliminating them. Here, we attempt to increase public health awareness of structural racism and its institutionalization and sociopolitical supports so that research and action can address them. This paper presents both a theoretic and an analytic approach to how structural racism contributes to disproportionate rates of HIV/AIDS and related diseases among oppressed populations. We first discuss differences in disease and health outcomes among people who use drugs (PWUD) and other groups at risk for HIV from different racial and ethnic populations. The paper then briefly analyzes the history of racism; how racial oppression, class, gender and other intersectional divisions interact to create health inequities; and how structural racism is institutionalized in ways that contribute to disease disparities among people who use drugs and other people. It examines the processes, institutions and other structures that reinforce structural racism, and how these, combined with processes that normalize racism, serve as barriers to efforts to counter and dismantle the structural racism that Black, indigenous and Latinx people have confronted for centuries. Finally, we discuss the implications of this analysis for public health research and action to undo racism and to enhance the health of populations who have suffered lifetimes of racial/ethnic oppression, with a focus on HIV/AIDS outcomes.

Individual and County-Level Disparities in Drug and Opioid Overdose Mortality for Hispanic Men in Massachusetts and the Northeast United States

BACKGROUND

This study aimed to identify individual- and county-level inequalities that may underlie disparities in drug overdose mortality for Hispanic men in Massachusetts and the broader Northeast region.

METHODS

The study first used data from the State Unintentional Drug Overdose Reporting System to compare the 635 Hispanic and 3593 Non-Hispanic (NH) White men who died of unintentional/undetermined opioid-related overdoses in Massachusetts in 2016-2018. Next, the study used 2015-2019 data from the Multiple Cause of Death online platform to: a) compare rates of drug overdose mortality in Hispanic versus NH White men in 54 counties in the Northeast United States; and b) examine associations with inequalities in poverty, educational attainment, unemployment, and uninsurance (from 2015-2019 American Community Survey data).

RESULTS

At the individual level, in Massachusetts, Hispanic and NH White men who died of opioid-related overdose differed in terms of educational attainment, birthplace, urbanicity, substance use disorder treatment history, and specific drugs involved in death. At the county level, in the Northeast region, each one-standard deviation increase in the ratio of the Hispanic to NH White poverty rate was associated with a 27% increase in the ratio of Hispanic to NH White male overdose mortality; each one-standard deviation increase in the ratio of the Hispanic to NH White unemployment rate was associated with a 43% increase in the ratio of Hispanic to NH White male overdose mortality.

CONCLUSIONS

Findings underscore the importance of equitable interventions and efforts to address inequalities in social determinants of health for Hispanic populations in the Northeast.

Predictors of intentional fentanyl use: Market availability vs consumer demand

BACKGROUND

Attempts to reduce opioid overdoses have been complicated by the dramatic rise in fentanyl use. While market forces contributing to fentanyl proliferation in the illicit drug supply have increased inadvertent exposure to the drug, rising fentanyl use may also be driven by growing consumer demand. Interventions to reduce the spread of fentanyl must be based on an understanding of the motivations underlying its use.

METHODS

Data for this cross-sectional study were derived from a computerized self-administered survey completed by a convenience sample of 432 people who use illicit opioids (PWUO) recruited from methadone and detoxification programs in NJ. The anonymous survey was based on a prior qualitative study of attitudes and behaviors surrounding opioid use. Multivariate analysis identified correlates of intentional fentanyl use in the full sample and among sub-populations of white and non-white PWUO.

RESULTS

In the full sample, intentional fentanyl use was associated with white race/ethnicity, younger age, polydrug use, and a preference for the drug effects of fentanyl, which more than tripled the probability of intentional use (AOR=3.02; 95% CI=1.86-4.89; p=.000). Among whites, a preference for the fentanyl drug effects was also the strongest predictor of intentional use (AOR=5.34; 95% CI=2.78-10.28; p=.000). Among non-whites, however, exposure, not preference, was the primary driver of use, with intentional use more than doubling (AOR=2.48; 95% CI=1.04-5.91; p<.05) among those living in high fentanyl dispersion counties.

CONCLUSION

The motivations underlying fentanyl use are multifactorial and vary across populations of PWUO, indicating a need for targeted interventions to counter the increasing spread and adverse consequences of fentanyl use. In order to counteract the increasing spread and adverse consequences of fentanyl use, these findings indicate a need for harm-reduction interventions, like drug testing or supervised injection sites, that address the differing motivations for fentanyl use among PWUO.

Risk of Drug Overdose Mortality for Island-Born and US-Born Puerto Ricans, 2013-2019

In the United States (US), individuals of Puerto Rican heritage die of drug overdoses at higher rates than other Hispanic groups or non-Hispanic Whites; yet, little is known about the extent to which drug overdose mortality affects island-born, versus US-born, Puerto Ricans. The distinction between Puerto Rican-born and US-born provides a starting point for culturally tailored services and interventions, as place of birth often informs language preferences and cultural identifications. Therefore, this study analyzed 2013-2019 death certificate data from the National Center for Health Statistics for 415,111 US deaths attributed to drug overdose. Drug overdose deaths were compared for island-born Puerto Ricans (N=3516), US-born Puerto Ricans (N=4949), and individuals not of Puerto Rican heritage (N=406,646). Drug overdose mortality rates, including age-specific and directly age-standardized rates, were calculated for each subgroup using population estimates from the US Census Bureau's American Community Survey. Results indicated that age-adjusted drug overdose mortality rates over the period of 2013-2019 were significantly higher for island-born than US-born Puerto Rican men (46.8 versus 34.6, per 100,000), with rates in both groups significantly higher than for men not of Puerto Rican heritage (24.0 per 100,000). For women, in contrast, drug overdose mortality rates were lower for island-born than US-born Puerto Ricans (8.6 versus 11.1, per 100,000). Within stateside Puerto Rican communities, island-born men experience a disproportionate burden of drug overdose mortality, necessitating targeted, culturally appropriate interventions built around the specific norms, circumstances, and lived experiences shared by Puerto Rican migrants who use drugs.