Rising Racial Disparities in Opioid Mortality and Undertreatment of Opioid Use Disorder and Mental Health Comorbidities in Virginia

Introduction

There were more than 100,000 fatal drug overdoses in the U.S. in 2021 alone. In recent years, there has been a shift in opioid mortality from predominantly White rural communities to Black urban communities. This study aimed to identify the Virginia communities disproportionately affected by the overdose crisis and to better understand the systemic factors contributing to disparities in opioid mortality.

Methods

Using the state all-payer claims database, state mortality records, and census data, we created a multivariate model to examine the community-level factors contributing to racial disparities in opioid mortality. We used generalized linear mixed models to examine the associations between socioecologic factors and fatal opioid overdoses, opioid use disorder diagnoses, opioid-related emergency department visits, and mental health diagnoses.

Results

Between 2015 and 2020, racial disparities in mortality widened. In 2020, Black males were 1.5 times more likely to die of an opioid overdose than White males (47.3 vs 31.6 per 100,000; p<0.001). The rate of mental health disorders strongly correlated with mortality (β=0.53, p<0.001). Black individuals are not more likely to be diagnosed with opioid use disorder (β=0.01, p=0.002) or with mental health disorders (β= -0.12, p<0.001), despite higher fatal opioid overdoses.

Conclusions

There are widening racial disparities in opioid mortality. Untreated mental health disorders are a major risk factor for opioid mortality. Findings show pathways to address inequities, including early linkage to care for mental health and opioid use disorders. This analysis shows the use of comprehensive socioecologic data to identify the precursors to fatal overdoses, which could allow earlier intervention and reallocation of resources in high-risk communities.

Cardiovascular Complications of Opioid Use: JACC State-of-the-Art Review

Opioids are the most potent of all analgesics. Although traditionally used solely for acute self-limited conditions and palliation of severe cancer-associated pain, a movement to promote subjective pain (scale, 0 to 10) to the status of a "fifth vital sign" bolstered widespread prescribing for chronic, noncancer pain. This, coupled with rising misuse, initiated a surge in unintentional deaths, increased drug-associated acute coronary syndrome, and endocarditis. In response, the American College of Cardiology issued a call to action for cardiovascular care teams. Opioid toxicity is primarily mediated via potent μ-receptor agonism resulting in ventilatory depression. However, both overdose and opioid withdrawal can trigger major adverse cardiovascular events resulting from hemodynamic, vascular, and proarrhythmic/electrophysiological consequences. Although natural opioid analogues are devoid of repolarization effects, synthetic agents may be proarrhythmic. This perspective explores cardiovascular consequences of opioids, the contributions of off-target electrophysiologic properties to mortality, and provides practical safety recommendations.

Is Europe facing an opioid crisis like the United States? An analysis of opioid use and related adverse effects in 19 European countries between 2010 and 2018

Background

Given the ongoing opioid crisis in the United States (US), we investigated the opioid situation in Europe. The aims of the study are to provide an overview of trends in prescription opioid (PO) use and opioid-related adversities between 2010 and 2018 for different opioids in 19 European countries and to present a comparison with similar data from the US.

Methods

A multisource database study with national data from 19 European countries evaluating trends between 2010 and 2018 in (a) PO consumption, (b) high-risk (HR) opioid users, (c) opioid-related hospital admissions, (d) opioid-related overdose deaths, (e) opioid use disorder treatment entries, and (f) patients in opioid substitution therapy (OST). Within and between-country comparisons and comparisons with data from the US were made.

Results

There was considerable variation between European countries. Most countries showed increased PO consumption with the largest increase and the highest consumption in the United Kingdom (UK) compared to the rest of Europe and the US in 2018 (UK: 58,088 defined daily doses for statistical purposes/1000 population/day). In 2018, Scotland had the highest rates (per 100,000 population) of HR opioid users (16·2), opioid-related hospital admissions (118), opioid-related deaths (22·7), opioid use disorder treatment admissions (190), and OST patients (555) of all included European countries. These rates were similar or even higher than those in the US in 2018. Other countries with high rates of opioid-related adversities were Northern Ireland (synthetic and “other” opioids), Ireland (heroin and methadone), and England (all opioids). All other countries had no or little increase in opioid-related adversities.

Conclusions

Apart from the British Isles and especially Scotland, there is no indication of an opioid crisis comparable to that in the US in the 19 European countries that were part of this study. More research is needed to identify drivers and develop interventions to stop the emerging opioid crisis in the UK and Ireland.

Community Versus Hospital Opioid-Related Overdose Deaths in Illinois

OBJECTIVE

To better understand approaches to reducing mortality from the opioid epidemic, we analyzed in-hospital versus community opioid-related overdose deaths in Illinois.

METHODS

We used data from the Statewide Unintentional Drug Overdose Reporting System (July 2017 through December 2018) to identify deaths that occurred in hospitals and communities (ie, homes or public spaces). We used census tract-level data for 34 Illinois counties to create bivariate mapping by overdose death rates. We used logistic regression to analyze the association of demographic and overdose characteristics with the likelihood of death in a hospital versus a community.

RESULTS

During the study period, 2833 opioid-related overdose deaths occurred in 24 Illinois counties, 655 (23.1%) of which occurred in the hospital; of 2178 community deaths, 1888 (86.7%) occurred in the same census tract as the decedent's recorded residence and 1285 (59.0%) occurred in the decedent's home. Non-Hispanic Black people were 1.63 (95% CI, 1.27-2.10) times more likely than non-Hispanic White people to die in a hospital. Decedents from suburban Cook County and other Chicago suburban counties were significantly more likely to die in the hospital than decedents from Chicago or other Illinois counties. Documentation of a previous overdose, history of opioid use, and having bystanders present were significantly associated with hospital deaths. Evidence of a rapid overdose, fentanyl present, or prescription opioids were significantly associated with deaths in a community.

CONCLUSIONS

The high number of opioid-related overdose deaths in the community illustrates the need to decriminalize illicit drug use and facilitate treatment seeking. Establishing supervised safe consumption sites may have the biggest effect in reducing the number of opioid-related overdose deaths.

Unclassified drug overdose deaths in the opioid crisis: emerging patterns of inequity

OBJECTIVE

Examine whether individual, geographic, and economic phenotypes predict missing data on specific drug involvement in overdose deaths, manifesting inequities in overdose mortality data, which is a key data source used in measuring the opioid epidemic.

MATERIALS AND METHODS

We combined national data sources (mortality, demographic, economic, and geographic) from 2014-2016 in a multi-method analysis of missing drug classification in the overdose mortality records (as defined by the use of ICD-10 T50.9 on death certificates). We examined individual disparities in decedent-level multivariate logistic regression models, geographic disparities in spatial analysis (heat maps), and economic disparities in a combination of temporal trend analyses (descriptive statistics) and both decedent- and county-level multivariate logistic regression models.

RESULTS

Our analyses consistently found higher rates of unclassified overdoses in decedents of female gender, White race, non-Hispanic ethnicity, with college education, aged 30-59 and those from poorer counties. Despite the fact that unclassified drug overdose death rates have reduced over time, gaps persist between the richest and poorest counties. There are also striking geographic differences both across and within states.

DISCUSSION

Given the essential role of mortality data in measuring the scale of the opioid epidemic, it is important to understand the individual and community inequities underlying the missing data on specific drug involvements. Knowledge of these inequities could enhance our understanding of the opioid crisis and inform data-driven interventions and policies with more equitable resource allocations.

CONCLUSION

Multiple individual, geographic, and economic disparities underlie unclassified overdose deaths, with important implications for public health informatics and addressing the opioid crisis.