The problem is not just increased use of stimulants and opioids, it is also a lack of recovery resources, substance use disorder treatment, and a historical mistrust of healthcare providers.
An exclusive interview with researcher Tarlise Townsend, Ph.D., reveals a definitive need for harm reduction policies plus investment in treatment in marginalized communities. In these communities, particularly lower-income African American and Latino neighborhoods, the opioid epidemic has combined with stimulant abuse to create a sharp spike in overdoses. These findings, from a study funded by the National Institutes of Health that examined death certificate data in the dozen years before the start of the COVID-19 pandemic, were published last month in the American Journal of Epidemiology.
Driven by the three-headed dragon of fentanyl, prescription painkillers, and heroin, drug overdoses kill over a hundred thousand people every year in the United States. However, from 2007 to 2019, drug overdose deaths involving more than one substance increased dramatically across the board nationwide. Additionally, these multi-drug overdoses had a more noticeable spike in traditionally marginalized communities that lack substance disorder education, prevention efforts, and treatment opportunities.
The Fix is honored to interview Dr. Tarlise Townsend about the implications of her study.
The Fix: Why is the combination of stimulant abuse like cocaine or methamphetamines and opioid use disorder like heroin or prescription painkiller misuse hitting marginalized racial and ethnic communities so hard? As opposed to one or the other, what do you think is the reason for the two-headed dragon?
Dr. Tarlise Townsend: The overarching response to that question, unfortunately, is that we don’t have an answer. Although we have diagnosed and identified the problem, we still desperately need to understand what’s driving it: Why are marginalized communities, particularly Black Americans, being hit proportionately hard by these combined overdose deaths? At the same time, the reality is that structural racism shapes everything, including access to resources. There is a lack of harm reduction options in this community, a historical lack of trust in healthcare providers, and a profound lack of access to treatment for substance use disorder.
Also, criminalization is a really big factor when it comes to the increased risk of overdose. It is so much less likely that authorities will be contacted in time to administer overdose antagonists like Naloxone. After all, Black Americans, particularly men, are so much more likely to be criminalized for just being in possession of these drugs.
As a result, there are many factors contributing to these racial disparities. Also, these disparities may not be specific to just these two types of drugs; stimulants and opioids. It may be a more systemic problem that right now is just manifesting as increased overdose due to the combination of stimulants and opioids. When you put this issue into the context of fundamental cause theory, you realize that the fundamental causes of health issues like socioeconomic status or racism affect health outcomes in almost every context in these communities. These overarching causes fundamentally affect people in so many ways because they basically bleed into everything.
Even if you try to address other causes of these health disparities, socioeconomic status and racism will find another way to generate other challenges. Indeed, socioeconomic status and racism have been and continue to be fundamental causes of adverse health outcomes in these marginalized communities. The problem is not just the increased use of stimulants and opioids leading to more overdoses. It also is a lack of recovery resources, educational opportunities, and substance use disorder treatment in these communities.
What drug is playing the driving role in this overdose crisis? Is heroin or cocaine proving to be more destructive in these communities?
Our study did not look specifically at the type of opioids contributing to these overdose deaths. However, other recent research looking at the problem of opioid-stimulant deaths has found that fentanyl is playing the driving role. The story of this rise in overdoses is due primarily to a surge in fentanyl exposure. There is a contamination of these street drugs that the person who is using does not realize. Despite the increase in combined opioid-stimulant use, the inclusion of fentanyl in that picture is the driving force.
In developing countries, particularly in Southeast Asia, methamphetamine use has been connected with working long hours. Is that happening in the U.S. as well?
I don’t feel like I can answer that question with any expertise or confidence, but it does bring up another perspective. There is evidence of people who use opioids in homeless populations on the street intentionally using stimulants to stay alert. First, these people are more readily targeted and criminalized for using. Second, they cannot afford to be oblivious when living in such extreme conditions. It could be that the stimulants counteract the opioids, allowing these people to avoid what we would describe as loitering and remain aware of external threats.
Thus, the co-use of these two drugs by homeless populations could be described as an effort to cope with really trying conditions. However, despite such hypotheses about what is going on, there is not a lot of proven research. Thus, we know very little about those specific dynamics. Still, the idea of homeless people addicted to opioids using stimulants as a survival mechanism is a notion that deserves greater investigation.
Specifically, what kind of harm reduction and evidence-based SUD treatment services are needed in Black and Latino neighborhoods? For example, if you had a billion dollars in funding to fight this crisis, how would you spend it?
We need to look at both the money is no object question, and money is an object, so what do we do question. For the first, we need all the things. There is no specific policy solution or harm reduction solution that is going to address everything. There is no quick and easy fix to eliminate rising disparities in opioid and stimulant overdose deaths. We would think that when we implement a societal health intervention, the population in our society that needs the most help will receive the most benefit from such an intervention. However, this is not the case because health disparities will often widen unless you specifically target the communities with the greatest needs. If you want to help those communities, you have to target the barriers preventing them from accessing the help they need, like resource barriers, stigma issues, socioeconomic gaps, and racial and ethnic challenges. Often, the people who benefit the most from societal health interventions are the people with the most resources. The lack of resources in marginalized communities results in such health interventions often proving ineffective.
In general, when we are thinking about policies and programs designed to target disparities in substance use and overdose, we need to be intentional about tailoring those interventions to the communities that need them most. We need culturally informed and competent efforts tailored to address the needs of these specific communities that are being hit the hardest by opioid and stimulant overdose deaths. Highlighting such tailoring, we need education and outreach materials translated into the languages primarily spoken in these communities. Awareness of substance use disorder treatment and harm reduction programs need to be raised in contexts that people in these communities trust. A great example is the role that Black churches are playing in Black communities. Since that setting implies a greater trust, it leads to a greater uptake of these recovery options. There is a lot of distrust in these communities when it comes to traditional healthcare settings.
Beyond these efforts, I also think we need to be thinking bigger. For example, the safe consumption sites that just opened in New York are encouraging, and initial evaluations are already underway. Researchers are looking at how effectively they reduce opioid mortality and increase the uptake of treatment for substance use disorder and other health intervention efforts. I’m also eager to see what effects decriminalization like we are seeing now in Oregon will have on overdose mortality trends. When it comes to spending money to combat these problems, whether it is the limited funds that are now accessible or an imaginary unlimited amount, researchers need in-depth cost-effectiveness analyses. No matter how much money is being spent, many health interventions that people thought would lead to major results did not give us the greatest bang for our buck. In reality, resources are limited and scarce. Thus, the money spent needs to be used in the best way possible. We need to study which of these programs and policies will prove cost-effective.
An example of such a cost-effective study is seen today in the use of Naloxone, the opioid antagonist that can reverse an overdose in an emergency. Distributing Naloxone to people who most likely will experience overdose is highly cost-effective and saves lives. It has proven to be one of the most cost-effective medications on the market. Our experience with Naloxone so far is a good model for figuring out how we can best use limited resources to address this crisis and reduce the health disparities in these marginalized communities.