Reflections on International Overdose Awareness Day During the COVID-19 Pandemic

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Today, August 31, is International Overdose Awareness Day. As the world reflects on the lives cut short due to drug overdoses, the opioid crisis is still raging in the United States in parallel with another public health crisis – the COVID-19 pandemic.  COVID-19 also ushered in new obstacles to overcome and navigate for those currently using opioids. Yet despite this setback, the work towards an overdose free world continues. Today, I want to give an overview of the most recent trends in the opioid crisis in Massachusetts, talk about a current gap in the treatment system, and how researchers in the Boston area, including ICH staff, are trying to better understand and address this gap.

Recent data from before COVID-19 has revealed that the opioid crisis is far from over. Nationally, fatal overdoses increased from 2018 to 2019, a reversal of a slight downward trend from 2017 to 2018. Here in Massachusetts, our overdose deaths peaked in 2016 with 2,102 deaths, with the deaths slightly decreasing every year throughout the end of 2019 which saw 2,015 deaths.

On January 30th, we saw the first documented case of local COVID-19 transmission in the United States. As it continued to spread, first in the hardest hit early states, then in the rest of the country, we saw our lives, economies, health care systems, and support systems grind to a halt. Yet while many aspects of life shut down, opioid use disorder and overdoses continued.  And according to preliminary reports, it appears that opioid overdoses, both fatal and non-fatal, are worsening due to the pandemic. While in Massachusetts, opioid deaths decreased in the first quarter of 2020 compared to 2019, the majority of these three months fell outside the COVID-19 lockdown. It’s uncertain if the second quarter will see a similar trend to the first as the treatment system has rapidly attempted to adapt and respond to this new reality.

To address the opioid crisis, it is critical to expand access to treatment as well as harm reduction resources. As researchers and evaluators, we’re not just charged with investigating if interventions work, but also who they work for and who they’re leaving out. In this spirit, the Boston Public Health Commission investigated the extent to which different racial/ethnic groups in Massachusetts and Boston access substance use treatment after an opioid overdose. Their report found:  

“Black and Hispanic residents in Massachusetts were 24% and 22%, respectively, less likely to receive substance misuse treatment within 30 days following hospital-related care for OOD in comparison with White residents, while Black and Hispanic residents in Boston were 49% and 31%, respectively, less likely to received similar treatment in comparison with White residents.”

So, while the recent opioid epidemic in Massachusetts has disproportionally affected white residents (although per capita overdose rates have increased for all groups and Hispanics overdose death rates have largely caught up to those of whites), the BPHC analysis shows that Black and Hispanic Boston residents were significantly less likely to receive treatment compared to White residents. Furthermore, we’ve seen largely working-class communities of color having higher instances of COVID-19 in Boston and Massachusetts. As of this writing, even as Massachusetts’ COVID cases have fallen significantly from the peak and remained somewhat stable, the East Boston community, a largely Hispanic immigrant working class community, has continued to have the highest positive testing rate within Boston, likely due to higher housing occupancy, existing health inequities driven by proximity to the airport, and working in frontline jobs with little power and pay.  Given these trends—lower access to substance use treatment among Black and Hispanic Bostonians, as well as higher instances of COVID-19 among these communities more broadly—the need for a better and actionable understanding of how inequities are being reproduced on a daily basis is critical.

As a follow-up to their study, the Boston Public Health Commission partnered with ICH, Boston University School of Public Health, and Boston Medical Center, with funding from RIZE Massachusetts Foundation, to conduct a qualitative research project to better understand the factors driving inequities in access to treatment, and to identify solutions local policy makers and programs can implement to help improve access to treatment, especially for Black and Hispanic Bostonians. We are also attempting to understand how the treatment system has been altered by COVID-19 and how this has affected Black and Hispanic Bostonians, and to identify recommendations that can inform the way the system evolves post-crisis. We will be doing this by conducting 60 qualitative interviews with Black, Hispanic, and White Bostonians who recently experienced an overdose to learn about their experiences post-overdose and the ways in which race/ethnicity factors in to their experiences and perspectives. We will also be speaking with various actors within the treatment system, from first responders to policy makers, to understand their view of Boston’s treatment system and the barriers to treatment experienced by Black and Hispanic Boston residents.  Throughout our data collection we’ll be sharing preliminary data back with key stakeholders, and we are currently working to find ways to have people who are currently using opioids participate in data interpretation and development of recommendations. After finishing the report, we will be disseminating the results and recommendations widely, as the ultimate aim is not just to understand the limits of the treatment system, but to change it for the better.

Jeffrey Desmarais, MA

Senior Research and Evaluation Project Manager