While it has been reported that opioid overdose deaths have increased during the COVID-19 pandemic, a new study looking at data in Philadelphia showed that this hardship has been overwhelmingly suffered by Black individuals. Researchers from the Perelman School of Medicine at the University of Pennsylvania analyzed the period of time after the city's stay-at-home order was announced in 2020 and showed that, compared to the year before, the number of fatal overdoses suffered by Black individuals spiked by more than 50 percent. At the same time, the rate for white individuals actually fell by 31 percent over the same period. This research was published in JAMA Network Open.
"Philadelphia has been devastated by the opioid crisis, which was experienced previously more acutely in the white community," said the study's lead author, Utsha Khatri, MD, a fellow in the National Clinician Scholars Program at Penn and an Emergency Medicine physician. "Recently, however, we tracked a disturbing trend toward higher rates of fatal and non-fatal overdoses among Black Philadelphia residents. These differential trends in opioid overdose suggest that racial inequities were exacerbated by the pandemic."
The Philadelphia Department of Public Health and the Philadelphia Fire Department published opioid overdose trends by race in 2020 after there were indications of a potential trend of increased overdose among Black Philadelphians. Eugenia South, MD, an assistant professor of Emergency Medicine and the senior author of this paper, took note of this and decided that it warranted a formal investigation to see whether these rates were by chance alone or actually statistically distinct from prior trends.
Khatri, South, and their fellow researchers, who included personnel from the Philadelphia Department of Public Health, used deidentified data available through the city's Substance Use Data Dashboard to look at numbers from three separate time periods: April through June 2019 (Period A), December 2019 through February 2020 (Period B), and April through June 2020 (Period C). The last period, C, was chosen because it took place in the full months following Pennsylvania's stay-at-home order for COVID-19, which was made official March 23. Period A was chosen because it offered a year-over-year comparison for the stay-at-home order's potential effects, and Period B gave a glimpse of the three months just before the order.
Overall, the data showed that fatal overdose rates in Philadelphia were unchanged over the same period between 2019 and 2020 (the monthly average for Period C was 98 deaths compared to Period A's 94 deaths). But when the researchers were able to break the numbers out by race, the story changed.
Among Black individuals, fatal overdoses went from a monthly average of around 30 -- both in 2019 and in the three months before the stay-at-home order -- to approximately 49 during April through June 2020. That accounted for an increase of more than 50 percent in both cases.
Meanwhile, during the post-stay-at-home period, white individuals actually experienced a decline in fatal overdoses, going from an average of 46 and 45 in Periods A and B, respectively, to just 35 in Period C. This was a sizable decrease, going down 31 percent year-over-year and 22 percent from the direct pre-stay-at-home order timeframe.
When looking at overdoses that did not result in death, these same racial trends were seen. Black individual averages went from 84 and 88 nonfatal overdoses in Periods A and B to 111 in Period C, an increase of more than 20 percent for both. In the same time periods, the numbers for whites went from 120 and 112 to 103, a decrease in nonfatal overdoses of more than 8 percent for each.
"The results of this study are sobering," South said. "The Black community has been hit incredibly hard since the start of the pandemic -- both with the illness itself and the social and economic fallout, which includes increased gun violence, job loss, and closure of small businesses. We believe the increase in fatal and non-fatal opioid overdoses is a symptom of that."
One of the study's co-authors, Kendra Viner, PhD, the director of the Philadelphia Department of Public Health's Division of Substance Use Prevention and Harm Reduction, explained one specific way that the pandemic's economic effects may have loomed large in these numbers.
"How this translated to an increase in accidental drug overdoses is unknown but may be related, in part, to the purchase of more economical drugs from less familiar sources," she said. "Our concern is that fentanyl, a potent synthetic opioid that is cheaper to produce and distribute, is increasingly being found in non-opioid drugs. This may put populations of drug users with no prior exposure to opioids at higher risk of overdose."
In addition to economic factors, the team theorized that another factor was a lack of equitable opioid treatment. Previous research has shown that buprenorphine, a medication used to soothe opioid cravings that must be prescribed by a doctor, is more available to white patients than those who are Black. And since research has shown that drug use is fairly similar across racial lines, but Black people are more likely to face legal penalties for it, Khatri emphasized that any expansion of treatment must reach those who have already been involved in the criminal justice system.
Moving forward, Viner said that her division plans to launch an outreach campaign to specifically deal with the potential dangers of fentanyl. This will likely include the distribution of naloxone, a medication that nearly instantly reverses opioid overdoses, and fentanyl test strips, which reveal the presence of fentanyl in other drugs so that it can be avoided.
While this study focused on Philadelphia, the researchers believe that it has some relevance to many places across the country. However, as this study showed, it's critical to analyze the data to confirm any potential trends. The researchers looked at cities across the country for opioid overdose data by race, but were unable to find any. Just as it was imperative early in the COVID-19 crisis to report cases by race to fully understand the extent of racial disparities in infection and death rates, health departments should publicly report opioid overdose rates by race.
"Cities across the country must examine trends in overdoses across various sociodemographic groups to have a more granular understanding of who is being affected and the best way to target response efforts," Khatri said.
All of that said, any amount of knowledge of disparities in opioid overdoses will require some buy-in for action, literal and otherwise.
"We must wonder, as a nation, are we willing to acknowledge these vast disparities and put real resources behind addressing them, as well as push forward new policy change that can address root causes?" South said.
This study was funded in part by the Centers for Disease Control and Prevention (grant number R01CE003143) and the Robert Wood Johnson Foundation Harold Amos Medical Faculty Development Program (76233).
Other authors on this study include Lia Pizzicato, Emily Bobyock, Monica Sun, and Zachary Meisel.
JAMA Network Open