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Open Access 01-12-2024 | Opioids | Research

Polysubstance mortality trends in White and Black Americans during the opioid epidemic, 1999–2018

Authors: Marwa Rawy, Gergis Abdalla, Kevin Look

Published in: BMC Public Health | Issue 1/2024

Abstract

Background

Psychoactive drug combinations are increasingly contributing to overdose deaths among White and Black Americans. To understand the evolving nature of overdose crisis, inform policies, and develop tailored and equitable interventions, this study provides a comprehensive assessment of polysubstance mortality trends by race and sex during the opioid epidemic.

Methods

We used serial cross-sectional US mortality data for White and Black populations from 1999 through 2018 to calculate annual age-adjusted death rates (AADR) involving any opioid, opioid subtypes, benzodiazepines, cocaine, psychostimulants, or combinations of these drugs, stratified by race and sex. Trend changes in AADR were analyzed using joinpoint regression models and expressed as average annual percent change (AAPC) during each period of the three waves of the opioid epidemic: 1999–2010 (wave 1), 2010–2013 (wave 2), and 2013–2018 (wave 3). Prevalence measures assessed the percent co-involvement of an investigated drug in the overall death from another drug.

Results

Polysubstance mortality has shifted from a modest rise in death rates due to benzodiazepine-opioid overdoses among White persons (wave 1) to a substantial increase in death rates due to illicit drug combinations impacting both White and Black populations (wave 3). Concurrent cocaine-opioid use had the highest polysubstance mortality rates in 2018 among Black (5.28 per 100,000) and White (3.53 per 100,000) persons. The steepest increase in death rates during wave 3 was observed across all psychoactive drugs when combined with synthetic opioids in both racial groups. Since 2013, Black persons have died faster from cocaine-opioid and psychostimulant-opioid overdoses. Between 2013 and 2018, opioids were highly prevalent in cocaine-related deaths, increasing by 33% in White persons compared to 135% in Blacks. By 2018, opioids contributed to approximately half of psychostimulant and 85% of benzodiazepine fatal overdoses in both groups. The magnitude and type of drug combinations with the highest death rates differed by race and sex, with Black men exhibiting the highest overdose burden beginning in 2013.

Conclusions

The current drug crisis should be considered in the context of polysubstance use. Effective measures and policies are needed to curb synthetic opioid-involved deaths and address disparate mortality rates in Black communities.

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Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 1999–2020. https://wonder.cdc.gov/controller/saved/D77/D305F620. Accessed 10 Sep 2022.

Ahmad FB, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. 2022. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. Accessed 20 Aug 2022.

Wilson N, Kariisa M, Seth P, Smith H, Davis NL. Drug and opioid-involved overdose deaths — United States, 2017–2018. MMWR Morb Mortal Wkly Rep. 2020;69:290–7.PubMedPubMedCentralCrossRef

Centers for Disease Control and Prevention. Understanding the Epidemic. https://www.cdc.gov/opioids/basics/epidemic.html. Accessed 15 Apr 2021.

Kariisa M, Scholl L, Wilson N, Seth P, Hoots B. Drug overdose deaths involving cocaine and psychostimulants with abuse potential — United States, 2003–2017. MMWR Morb Mortal Wkly Rep. 2019;68:388–95.PubMedPubMedCentralCrossRef

Ciccarone D. The rise of illicit fentanyls, stimulants and the fourth wave of the opioid overdose crisis. Curr Opin Psychiatry. 2021;34:344–50.PubMedPubMedCentralCrossRef

Jones CM, Bekheet F, Park JN, Alexander GC. The evolving overdose epidemic: synthetic opioids and rising stimulant-related harms. Epidemiol Rev. 2020;42:154–66.PubMedCrossRef

Dowell D, Noonan RK, Houry D. Underlying factors in drug overdose deaths. JAMA. 2017;318:2295–6.PubMedPubMedCentralCrossRef

Centers for Disease Control and Prevention. Drug overdose deaths. https://www.cdc.gov/drugoverdose/deaths/other-drugs.html. Accessed 20 Apr 2021.

10.

Cicero TJ, Ellis MS, Kasper ZA. Polysubstance use: a broader understanding of substance use during the opioid crisis. Am J Public Health. 2020;110:244–50.PubMedPubMedCentralCrossRef

11.

Drug Enforcement Administration. 2019 National Drug Threat Assessment. https://www.dea.gov/documents/2020/01/30/2019-national-drug-threat-assessment. Accessed 17 Mar 2021.

12.

Jones CM, Einstein EB, Compton WM. Changes in synthetic opioid involvement in drug overdose deaths in the United States, 2010–2016. JAMA. 2018;319:1819–21.PubMedPubMedCentralCrossRef

13.

Suzuki J, El-Haddad S. A review: fentanyl and non-pharmaceutical fentanyls. Drug Alcohol Depend. 2017;171:107–16.PubMedCrossRef

14.

Blondino CT, Gormley MA, Taylor DDH, Lowery E, Clifford JS, Burkart B, et al. The Influence of co-occurring substance use on the effectiveness of opiate treatment programs according to intervention type. Epidemiol Rev. 2020;42:57–78.PubMedCrossRef

15.

O’Brien P, Henke RM, Schaefer MB, Lin J, Creedon TB. Utilization of treatment by Medicaid enrollees with opioid use disorder and co-occurring substance use disorders. Drug Alcohol Depend. 2020;217:108261.PubMedCrossRef

16.

Lin LA, Bohnert ASB, Blow FC, Gordon AJ, Ignacio RV, Kim HM, et al. Polysubstance use and association with opioid use disorder treatment in the US veterans health administration. Addiction. 2021;116:96–104.PubMedCrossRef

17.

Chan B, Freeman M, Kondo K, Ayers C, Montgomery J, Paynter R, et al. Pharmacotherapy for methamphetamine/amphetamine use disorder—a systematic review and meta-analysis. Addiction. 2019;114:2122–36.PubMedCrossRef

18.

Chan B, Kondo K, Freeman M, Ayers C, Montgomery J, Kansagara D. Pharmacotherapy for cocaine use disorder—a systematic review and meta-analysis. J Gen Intern Med. 2019;34:2858–73.PubMedPubMedCentralCrossRef

19.

Fairbairn N, Coffin PO, Walley AY. Naloxone for heroin, prescription opioid, and illicitly made fentanyl overdoses: challenges and innovations responding to a dynamic epidemic. Int J Drug Policy. 2017;46:172–9.PubMedPubMedCentralCrossRef

20.

Meghani SH, Byun E, Gallagher RM. Time to take stock: a meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain Med. 2012;13:150–74.PubMedCrossRef

21.

Pletcher MJ, Kertesz SG, Kohn MA, Gonzales R. Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. JAMA. 2008;299:70–8.PubMedCrossRef

22.

James K, Jordan A. The opioid crisis in black communities. J Law Med Ethics. 2018;46:404–21.PubMedCrossRef

23.

Alexander MJ, Kiang MV, Barbieri M. Trends in black and white opioid mortality in the United States, 1979–2015. Epidemiology. 2018;29:707–15.PubMedPubMedCentralCrossRef

24.

Substance Abuse and Mental Health Services Administration. The Opioid Crisis and the Black/African American Population: An Urgent Issue. 2020. https://store.samhsa.gov/product/The-Opioid-Crisis-and-the-Black-African-American-Population-An-Urgent-Issue/PEP20-05-02-001. Accessed 30 Mar 2021.

25.

Jordan A, Mathis M, Haeny A, Funaro M, Paltin D, Ransome Y. An evaluation of opioid use in black communities: a rapid review of the literature. Harv Rev Psychiatry. 2021;29:108–30.PubMedPubMedCentralCrossRef

26.

Furr-Holden D, Milam AJ, Wang L, Sadler R. African Americans now outpace whites in opioid-involved overdose deaths: a comparison of temporal trends from 1999 to 2018. Addiction. 2021;116:677–83.PubMedCrossRef

27.

Kariisa M, Seth P, Scholl L, Wilson N, Davis NL. Drug overdose deaths involving cocaine and psychostimulants with abuse potential among racial and ethnic groups – United States, 2004–2019. Drug Alcohol Depend. 2021;227:109001.PubMedCrossRef

28.

Johnson K, Jones C, Compton W, Baldwin G, Fan J, Mermin J, et al. Federal response to the opioid crisis. Curr HIV/AIDS Rep. 2018;15:293–301.PubMedCrossRef

29.

Ruhm CJ. Nonopioid overdose death rates rose almost as fast as those involving opioids, 1999–2016. Health Aff. 2019;38:1216–24.CrossRef

30.

von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg. 2014;12:1495–9.CrossRef

31.

Ingram DD, Malec DJ, Makuc DM, et al. National Center for Health Statistics Guidelines for Analysis of Trends. Vital Health Stat 2(179). 2018. https://www.cdc.gov/nchs/data/series/sr_02/sr02_179.pdf. Accessed 2 Mar 2020.

32.

Centers for Disease Control and Prevention. National Center for Health Statistics. Mortality multiple cause files. https://www.cdc.gov/nchs/data_access/vitalstatsonline.htm#Mortality_. Accessed 10 Mar 2020.

33.

Jones CMC, Baldwin GT, Compton WM. Recent increases in cocaine-related overdose deaths and the role of opioids. Am J Public Health. 2017;107:430–2.CrossRef

34.

National Cancer Institute. Joinpoint Regression Program (Version 4.8.0.1) [computer software]. 2020.

35.

Centers for Disease Control and Prevention. U.S. Census Populations With Bridged Race Categories 1999 to 2018 request. https://www.cdc.gov/nchs/nvss/bridged_race.htm. Accessed 13 Mar 2020.

36.

Curtin LR, Klein RJ. Direct standardization (age-adjusted death rates). Healthy People 2000 Stat Notes. 1995:1–10.

37.

Levy B, Paulozzi L, Mack KA, Jones CM. Trends in opioid analgesic prescribing rates by specialty, U.S., 2007–2012. Am J Prev Med. 2015;49:409–13.PubMedPubMedCentralCrossRef

38.

Bachhuber MA, Hennessy S, Cunningham CO, Starrels JL. Increasing benzodiazepine prescriptions and overdose mortality in the United States, 1996–2013. Am J Public Health. 2016;106:686–8.PubMedPubMedCentralCrossRef

39.

Hwang CS, Kang EM, Kornegay CJ, Staffa JA, Jones CM, McAninch JK. Trends in the concomitant prescribing of opioids and benzodiazepines, 2002–2014. Am J Prev Med. 2016;51:151–60.PubMedCrossRef

40.

Patrick SW, Fry CE, Jones TF, Buntin MB. Implementation of prescription drug monitoring programs associated with reductions in opioid-related death rates. Health Aff. 2016;35:1324–32.CrossRef

41.

Zhang VS, Olfson M, King M. Opioid and benzodiazepine coprescribing in the United States before and after US food and drug administration boxed warning. JAMA Psychiat. 2019;76:1208–10.CrossRef

42.

Green TC, Gilbert M. Counterfeit medications and fentanyl. JAMA Intern Med. 2016;176:1555–7.PubMedCrossRef

43.

LaRue L, Twillman RK, Dawson E, Whitley P, Frasco MA, Huskey A, et al. Rate of fentanyl positivity among urine drug test results positive for cocaine or methamphetamine. JAMA Netw Open. 2019;2:e192851.PubMedPubMedCentralCrossRef

44.

Carroll JJ, Marshall BDL, Rich JD, Green TC. Exposure to fentanyl-contaminated heroin and overdose risk among illicit opioid users in Rhode Island: a mixed methods study. Int J Drug Policy. 2017;46:136–45.PubMedPubMedCentralCrossRef

45.

Gladden RM, O’Donnell J, Mattson CL, Seth P. Changes in opioid-involved overdose deaths by opioid type and presence of benzodiazepines, cocaine, and methamphetamine — 25 states, July–December 2017 to January–June 2018. MMWR Morb Mortal Wkly Rep. 2019;68:737–44.PubMedPubMedCentralCrossRef

46.

Hoots B, Vivolo-Kantor A, Seth P. The rise in non-fatal and fatal overdoses involving stimulants with and without opioids in the United States. Addiction. 2020;115:946–58.PubMedCrossRef

47.

Hoopsick RA, Homish GG, Leonard KE. Differences in opioid overdose mortality rates among middle-aged adults by race/ethnicity and sex, 1999–2018. Public Health Rep. 2021;136:192–200.PubMedCrossRef

48.

Phelan JC, Link BG. Is racism a fundamental cause of inequalities in health? Annu Rev Sociol. 2015;41:311–30.CrossRef

49.

Andraka-Christou B. Addressing racial and ethnic disparities in the use of medications for opioid use disorder. Health Aff. 2021;40:920–7.CrossRef

50.

Cummings JR, Wen H, Ko M, Druss BG. Race/ethnicity and geographic access to Medicaid substance use disorder treatment facilities in the United States. JAMA Psychiat. 2014;71:190–6.CrossRef

51.

Goedel WC, Shapiro A, Cerdá M, Tsai JW, Hadland SE, Marshall BDL. Association of racial/ethnic segregation with treatment capacity for opioid use disorder in counties in the United States. JAMA Netw Open. 2020;3:1–10.CrossRef

52.

Guadamuz JS, Wilder JR, Mouslim MC, Zenk SN, Alexander GC, Qato DM. Fewer pharmacies in black and hispanic/latino neighborhoods compared with white or diverse neighborhoods, 2007–15. Health Aff. 2021;40:802–11.CrossRef

53.

Martha Hostetter and Sarah Klein, “Understanding and Ameliorating Medical Mistrust Among Black Americans,” Transforming Care. Commonwealth Fund. 2021. https://doi.org/10.26099/9grt-2b21.

54.

Saloner B, Cook BL. Blacks and hispanics are less likely than whites to complete addiction treatment, largely due to socioeconomic factors. Health Aff. 2013;32:135–45.CrossRef

55.

Latimore AD, Bergstein RS. “Caught with a body” yet protected by law? Calling 911 for opioid overdose in the context of the Good Samaritan Law. Int J Drug Policy. 2017;50:82–9.PubMedCrossRef

56.

Camplain R, Sabo S, Baldwin JA, Camplain C, Pro G, Trotter RT, et al. Racial/ethnic differences in drug- and alcohol-related arrest outcomes in a Southwest County from 2009 to 2018. Am J Public Health. 2020;110:S85–92.PubMedPubMedCentralCrossRef

57.

Mital S, Wolff J, Carroll JJ. The relationship between incarceration history and overdose in North America: a scoping review of the evidence. Drug Alcohol Depend. 2020;213:108088.PubMedPubMedCentralCrossRef

58.

Center for Behavioral Health Statistics and Quality. Results from the 2019 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration. 2020. https://www.samhsa.gov/data/report/2019-nsduh-detailed-tables. Accessed 10 Aug 2021.

59.

Cicero TJ, Wong G, Tian Y, Lynskey M, Todorov A, Isenberg K. Co-morbidity and utilization of medical services by pain patients receiving opioid medications: data from an insurance claims database. Pain. 2009;144:20–7.PubMedPubMedCentralCrossRef

60.

Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B, Riley JL. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain. 2009;10:447–85.PubMedPubMedCentralCrossRef

61.

McHugh RK, Votaw VR, Sugarman DE, Greenfield SF. Sex and gender differences in substance use disorders. Clin Psychol Rev. 2018;66:12–23.PubMedCrossRef

62.

Statistical methods: Suppression of rates and counts. Centers for Disease Control and Prevention. https://www.cdc.gov/cancer/uscs/technical_notes/stat_methods/suppression.htm. Accessed 7 Nov 2023.

63.

Arias E, Heron M, Hakes J. The validity of race and hispanic-origin reporting on death certificates in the United States: an update. Vital Health Stat. 2016;2:1–21.

64.

Joshi S, Weiser T, Warren-Mears V. Drug, opioid-involved, and heroin-involved overdose deaths among American Indians and Alaska Natives — Washington, 1999–2015. MMWR Morb Mortal Wkly Rep. 2018;67:1384–7.PubMedPubMedCentralCrossRef

65.

Ruhm CJ. Corrected US opioid-involved drug poisoning deaths and mortality rates, 1999–2015. Addiction. 2018;113:1339–44.PubMedCrossRef

66.

Buchanich JM, Balmert LC, Williams KE, Burke DS. The effect of incomplete death certificates on estimates of unintentional opioid-related overdose deaths in the united states, 1999–2015. Public Health Rep. 2018;133:423–31.PubMedPubMedCentralCrossRef

67.

Clinton HA, Thangada S, Gill JR, Mirizzi A, Logan SB. Improvements in toxicology testing to identify fentanyl analogs and other novel synthetic opioids in fatal drug overdoses, connecticut, January 2016–June 2019. Public Health Rep. 2021;1361_suppl:80S–86S.CrossRef

68.

Warner M, Paulozzi LJ, Nolte KB, Davis GG, Nelson LS. State variation in certifying manner of death and drugs involved in drug intoxication deaths. Acad Forensic Pathol. 2013;3:231–7.CrossRef

69.

Centers for Disease Control and Prevention. Increase in fatal drug Overdoses across the United States driven by synthetic opioids before and during the COVID-19 pandemic. CDC Health Alert Network. 2020. https://emergency.cdc.gov/han/2020/han00438.asp. Accessed 3 Jan 2021.

70.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. (DSM-5®). Washington, DC: American Psychiatric Association; 2013.

71.

Peppin JF, Raffa RB, Schatman ME. The polysubstance overdose-death crisis. J Pain Res. 2020;13:3405–8.PubMedPubMedCentralCrossRef

72.

Peiper NC, Clarke SD, Vincent LB, Ciccarone D, Kral AH, Zibbell JE. Fentanyl test strips as an opioid overdose prevention strategy: findings from a syringe services program in the Southeastern United States. Int J Drug Policy. 2019;63:122–8.PubMedCrossRef

73.

Barry CL. Fentanyl and the evolving opioid epidemic: what strategies should policy makers consider? Psychiatr Serv. 2018;69:100–3.PubMedCrossRef

74.

Joudrey PJ, Adams ZM, Bach P, Van BS, Chaiton JA, Ehrenfeld L, et al. Methadone access for opioid use disorder during the COVID-19 pandemic within the United States and Canada. JAMA Netw Open. 2021;4:e2118223.PubMedPubMedCentralCrossRef

75.

Spencer MR, Miniño AM, Warner M. Drug overdose deaths in the United States, 2001–2021. NCHS Data Brief, no 457. Hyattsville, MD: National Center for Health Statistics. 2022. https://doi.org/10.15620/cdc:122556.

76.

Friedman JR, Hansen H. Evaluation of increases in drug overdose mortality rates in the US by race and ethnicity before and during the COVID-19 pandemic. JAMA Psychiat. 2022;79:379.CrossRef

Title: Polysubstance mortality trends in White and Black Americans during the opioid epidemic, 1999–2018
Authors: Marwa Rawy
Gergis Abdalla
Kevin Look
Publication date: 01-12-2024
Publisher: BioMed Central
Keywords: Opioids
Opioids
Benzodiazepine
Published in: BMC Public Health / Issue 1/2024
Electronic ISSN: 1471-2458
DOI: https://doi.org/10.1186/s12889-023-17563-x

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Polysubstance mortality trends in White and Black Americans during the opioid epidemic, 1999–2018

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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