July 28, 2022, 3:05 p.m. Michael Devitt — As the COVID-19 pandemic unfolded across the United States in 2020, millions of Americans were unable to access much-needed services for the treatment and prevention of substance use disorders, particularly in areas with high increases in income inequality. Those factors, combined with longstanding health disparities among certain racial and ethnic groups, contributed to one of the largest year-to-year increases in drug overdose deaths in recent history.
Those are among findings published July 22 in the CDC’s Morbidity and Mortality Weekly Report. Nearly 92,000 drug overdose deaths occurred in the United States in 2020, an increase of almost 30% over the previous year, with the highest increases occurring among Black and American Indian/Alaska Native individuals.
The report’s findings are in line with a Vital Statistics Rapid Release from last July, which estimated at the time that more than 93,000 drug overdose deaths occurred in 2020.
“During — and now as the COVID pandemic wanes — a significant number of our patients have been affected by substance abuse and overdose, particularly if one practices in an area where there are populations impacted by health inequalities,” family physician Robert “Chuck” Rich, M.D., told AAFP News. “Our services are particularly needed by these marginalized populations, especially if you provide substance abuse care.”
In the report, researchers used data from the State Unintentional Drug Overdose Reporting System in 25 states and the District of Columbia to compare overdose death rates from 2019 to 2020. Death rates were age-adjusted and classified into five racial and ethnic groups.
The report also compared drug overdose death rates based on a variety of social determinants, including county-level income inequality ratios, as well as the availability of mental health professionals, opioid treatment programs and the health care professionals who could prescribe buprenorphine.
While drug overdose death rates increased from year to year among every measured racial and ethnic group, the relative increases were highest in Black (44%) and American Indian/Alaska Native individuals (39%). Among white individuals, the overdose death rate increased by 22%.
In three groups (Black, white and Hispanic individuals), the largest relative rate increases from year to year occurred among those ages 15 to 24 years.
While more than three-quarters of people who died from drug overdose in 2020 had a documented history of substance use or evidence of a substance use disorder, the number of people with a documented history of treatment for substance use or misuse was substantially lower, especially among racial minorities; only about 10% of Hispanic and American Indian/Alaska Native people, and just over 8% of Black people, had a history of receiving substance use treatment, compared with about 16% of white individuals.
Focusing more on social determinants, the researchers noted that the overdose death rate for Black and Hispanic individuals was more than twice as high in areas of highest income inequality compared to areas with the lowest income inequality.
In areas with higher capacity for treating mental health conditions, overall drug overdose death rates were higher, in particular for Black people; in counties with the highest level of mental health care professional availability, the drug overdose death rate for Black people was more than 2.5 times as high as the rate in areas with the lowest level of availability.
Similarly, in counties with at least one opioid treatment program, the opioid-involved overdose death rate for Black people was more than twice as high as in counties without such programs. In addition, in counties with higher potential capacity of health care professionals who could provide buprenorphine, the opioid-involved death rate among Black people was nearly three times higher than in counties with low potential capacity.
Researchers said that while areas with a high prevalence of substance use may also have a greater proportion of treatment services, “this higher potential treatment capacity might not reflect treatment services that are accessible to community members, especially in counties that cover large geographic areas.” They also noted that where health care professionals are clustered in densely populated areas, people in less populated areas could face transportation barriers to treatment.
The pandemic, the authors said, has brought longstanding health care disparities among certain racial and ethnic minorities to the forefront. To combat these issues and reduce drug overdose death rates, they called for evidence-based, culturally responsive prevention efforts that address both substance use and social determinants to reduce inequities in prevention, treatment and harm reduction.
To overcome barriers to access, the authors also called for structural and policy-level interventions, including efforts to expand linkage to care, retention in care, equitable access to treatment and behavioral health interventions, as well as harm reduction services. In addition, they recommended expanding prevention efforts that focus on adverse childhood experiences and implementing trauma-informed care and related services.
“Drug overdoses are preventable, and rapidly scaling up multisectorial, culturally responsive prevention efforts across federal, state, local and tribal entities that place equity as a central tenet to address the escalating overdose crisis is urgently needed,” they concluded.
Rich, medical director of Bladen Medical Associated in Elizabethtown, N.C., and a clinical adjunct professor at Campbell University School of Osteopathic Medicine in Buies Creek, N.C., has served as the AAFP’s representative on the AMA Task Force to Reduce Opioid Abuse and contributed to the development of a CDC guideline on prescribing opioids for chronic pain. He cited the lack of available services for SUD and OUD as a main barrier to care, especially in areas where many marginalized populations reside. At the same time, he viewed the lack of services as an opportunity for family physicians to fill that void.
“Since many of our members practice in various underserved areas and confront inequities of many types daily, family physicians are ideally suited to improve these inequities by adding SUD care to their services, including medication-assisted treatment,” said Rich.
“In such areas, our members are often knowledgeable about the local resources to help meet those disparities but need the additional financial support to help link patients to resources,” Rich continued. “We are accustomed to helping link our patients to resources but to do so requires physician and staff time, which is not routinely covered by typical billing codes as part of routine patient encounters.”
Rich offered advice for AAFP members who may just be starting to work in areas affected by health disparities.
“Typically, established health care professionals already have the contact to such services,” Rich said, adding that these clinicians may be good resources. “When they don’t, local social service departments, health departments, division of aging departments and local houses of worship are places an FP can turn to for assistance in finding local resources.”
Rich also recommended AAFP tools such as the Pain Management & Opioid Misuse webpage, which contains links to resources including the Chronic Pain Management Toolkit, an OUD treatment practice manual, patient education materials, policy statements, journal article collections and the Provider Clinical Support System (PCSS).
“AAFP is a partner organization aligned with PCSS for the expansion of SUD care, and our members can find a large amount of information there about SUD care, including MAT waiver training courses, which can be taken online,” said Rich.
“I would also remind our members about the additional educational offerings provided by our state chapters on the subject,” Rich said. “And I would also highlight the American Academy of Pain Medicine as another resource our members can turn to.”
Finally, Rich asked that more family physicians get involved in caring for patients with SUD, and that more support be given to clinicians already offering these services.
“We need more members trained in providing SUD care, including MAT,” Rich said. “We need more of our members practicing in areas affected by health disparities. And as a country, we must devote more resources to providing SUD care and addressing health disparities in our underserved regions, including greater support of our members currently providing that care.”
Some of the AAFP’s recent advocacy includes support for legislation that would improve access to MAT, steps to address overprescribing that do not burden physicians or patients, and permanent flexibility for physicians to prescribe OUD treatment via telehealth.