The nation’s drug overdose epidemic has worsened since COVID-19, creating a twindemic of sorts in the United States.
“From 2020 to 2021, overdose deaths exceeded 100,000 for the first time ever. No community or demographic is untouched,” according to Bobby Mukkamala, MD, chair of the AMA Substance Use and Pain Care Task Force.
The epidemic has been fed by a dramatic increase in the use of illicit fentanyl and fentanyl analogs, methamphetamine and cocaine. In tracking these developments, Dr. Mukkamala urged physicians to look closely at their practices “to ensure that we address any health inequities that might negatively affect our Black and brown patients—and we advocate to policymakers that all barriers to evidence-based care must be removed, including social determinants of health that may impede timely, affordable access to that care.”
Looking at the epidemic by race and ethnicity, things aren’t equal, said Dr. Mukkamala, who also chairs the AMA Board of Trustees. For example, patients who receive buprenorphine for opioid-use disorder are overwhelmingly white, whereas the patients receiving methadone are overwhelmingly Black.
“This data needs assessment and work to ensure that all of us have access to the best care for our needs,” he said. Research published within the last year by JAMA®, the Department of the Health and Human Services Office of the Inspector General (PDF) and the Foundation for Opioid Response Efforts (PDF) have highlighted the issue.
He and several other physician experts addressed the struggles that patients from historically marginalized racial and ethnic groups face during an AMA Advocacy Insights webinar, and what can be done to support these patients.
A community problem
Looking at Black and brown communities, “we have to talk about oppression and racism through the years,” which has fueled self-medication through street drugs, said Edwin C. Chapman, MD.
Dr. Chapman is founding member and secretary of the board of directors at the Leadership Council for Healthy Communities, a Washington-based nonprofit of clergy, medical professionals, public and community leaders working together to help African Americans and other historically marginalized racial and ethnic groups eliminate health inequities and promote healthy communities through comprehensive programs.
Among Black people, there has been a dramatic shift from heroin to illicit fentanyl. In Washington, “we went from 20% fentanyl in 2015 to 95% fentanyl in 2020 and 2021,” said Dr. Chapman.
Diseases of disparity often take place in communities that have gone through dramatic economic changes. For a study published in JAMA Internal Medicine, researchers examined the closure of automobile assembly plants and found a marked increase in opioid-related mortality in affected communities. There was an 85% increase in mortality, noted Dr. Chapman.
Drug overdose affects the entire community, he continued. Many factors are at play: community stigma, lack of opportunities for insurance coverage, employment and housing, government apathy, and inequitable access to pharmaceutical treatment.
Read why this is a critical year to address the worsening drug-overdose crisis.
Treatment instead of punishment
There are also racial and ethnic inequities in incarceration patterns, compared with access to addiction treatment, Dr. Chapman said. Solutions call for an approach that involves medical treatment, advocacy, legal surveillance and support systems for employment, education and other basic needs, he said.
The criminal justice system and outpatient treatment need to form better connections, he added. One concept—law enforcement assisted diversion—involves taking people to treatment centers instead of jails.
“If a person overdoses and goes to the hospital, they should be started on medication before they leave the emergency room,” Dr. Chapman said. This approach is still a work in progress in many areas of the country, he acknowledged.
After the webinar was recorded, the Biden administration sent its first national drug-control strategy (PDF) to Congress with a focus on harm reduction, which was welcomed by the AMA.
“This sober, clear-eyed report sees the nation’s drug overdose and death epidemic as a public health emergency that requires increased access to a wide variety of harm reduction efforts,” Dr. Mukkamala said in a statement. “Such approaches as increased access to naloxone, drug test strips and syringe services are evidence- based, and, if enacted, would save thousands of lives. We look forward to working with the administration on expanding harm-reduction options for our patients. We also agree with the need to remove all barriers to medications to treat opioid-use disorder, including barriers from health insurers as well as those encountered by incarcerated patients and those in recovery homes.”
Removing barriers to care
AMA and Manatt Health have issued a state toolkit (PDF) that identifies immediate actions to prevent more loss of life. “It means addressing disparities and the needs of all patients equitably,” said Dr. Mukkamala during the webinar.
For example, after a successful pilot program Maine has committed (PDF) to providing medications to treat opioid-use disorder at all correctional facilities in the state.
Meanwhile, New York has implemented a program that trains people who were incarcerated, their family members and corrections staff to recognize and respond to the signs of opioid overdose, and provides naloxone kits to incarcerated people upon release.
The AMA believes that science, evidence, and compassion must continue to guide patient care and policy change as the nation’s opioid epidemic has become a more dangerous and complicated illicit drug overdose epidemic. Learn more at the AMA's End the Epidemic website.
