E: Root Causes of Opioid Epidemic: Deep Dive
Introduction
Substance use disorders (SUDs) are complex conditions with multifaceted etiologies (SAMHSA, 2021). The diathesis-stress biopsychosocial model proposes that SUDs arise from an interplay of genetic predispositions and environmental factors (Koob & Volkow, 2010). Substance use disorders are prevalent within marginalized communities, contributing to the "diseases of despair" that disproportionately affect these populations (SAMHSA, 2021). Economic deprivation, limited opportunities, and social exclusion significantly affect population health, particularly among historically marginalized groups (Geronimus et al., 2021).
The War on Drugs
The War on Drugs has had a profound impact on urban communities, particularly since the 1970s (Alexander, 2010). Discriminatory drug policies, such as the disparity in sentencing for cocaine and crack cocaine possession, have led to the mass incarceration of Black and Hispanic individuals (Alexander, 2010). This loss of working-aged adults has exacerbated economic disinvestment in these communities (Pettit & Western, 2004). Reluctance to treat substance use disorders as a health issue and instead utilize the criminal justice system, especially for Black individuals, has resulted in less than 10% of individuals receiving the treatment they need (Newsome, 2022). "In the African American community, drug addiction has always been and continues to be seen as a moral problem, and incarceration was the treatment" (Newsome, 2022).
Overprescribing and Diversion of Prescription Opioids
The introduction of prescription opioids for pain management, combined with aggressive marketing and minimized information about their addictive potential, created a perfect storm for the opioid crisis (Dowell et al., 2016). Prescription opioids have also fueled the illicit opioid market, with studies showing that a large percentage of heroin users report first using prescription opioids.
The Role of Fentanyl
Illicit fentanyl, produced and trafficked by cartels, has exacerbated the opioid crisis, leading to a surge in overdose deaths (Jones et al., 2021). The high potency and low cost of fentanyl have made it attractive to drug cartels, who see it as a profitable commodity (Cicero et al., 2021). Overdose fatalities involving synthetic opioids increased nearly six-fold between 2015 and 2020, from 3.1 to 17.8 deaths per 100,000 people across the U.S. Research published in JAMA showed the pandemic was associated with a drop in medical prescriptions for opioids and subsequent work suggests this only occurred for new users rather than for those previously prescribed opioids (Warraich, 2022). A recent study has shown that the sudden stopping of prescription opioids increases the risk of suicide as it induces people to substitute illicit opioids like heroin and fentanyl (Warraich, 2022).
Racial Disparities in Overdose Deaths
The Black population has been disproportionately affected by fentanyl overdoses (CDC, 2021). Due to historical heroin use and systemic racism, Black individuals have been more likely to be exposed to fentanyl-laced heroin (Jones et al., 2021). Since 2015, the overdose death rate among Black men has risen 213% (Gramlich, 2022). In a survey of individuals serving this population (Banks, 2023), four items were identified that impact opioid overdoses among Black people: (1) racially inequitable funding systems, (2) resource deserts in Black communities, (3) lack of opportunities to build social capital and engage in healthy, adaptive activities, and (4) the over-criminalization of Black communities, particularly drug criminalization. In addition, four ways systemic racism manifests in healthcare were identified: (1) poor perceived treatment quality, (2) lack of service capacity, (3) prohibitive cost of care, and (4) prohibitive eligibility/intake criteria (Banks, 2023).
Individuals with a history of discrimination, poverty, and lack of political power have been particularly vulnerable to substance use disorders (SAMHSA, 2021). The stigmatization of substance use as a moral failing has amplified these disparities (Link & Phelan, 2001). Social determinants of health, such as poverty, unemployment, and lack of access to healthcare, are linked to increased SUD risk (SAMHSA, 2021). Structural racism creates systemic barriers that contribute to health disparities, including increased SUD risk among marginalized communities (Bailey et al., 2017). A lack of the 4Ss (safety, security, stability, and survival) are associated with health and social consequences that perpetuate opioid use, overdose events, and detrimentally impact recovery efforts (Banks, 2022). For example, people considering treatment are concerned that dealing with the social service system can cause them to lose their employment, housing, or even custody of their children (Newsome, 2022).
Rural Communities
While the War on Drugs devastated urban areas, rural communities simultaneously experienced economic decline, leading to a different type of despair (Case & Deaton, 2015).
Personal and Generational Trauma
SUDs are characterized by changes in brain reward pathways, leading to increased dependence and addiction (Koob & Volkow, 2010). Individuals with a family history of SUDs may have genetic vulnerabilities that predispose them to addiction (SAMHSA, 2021). Exposure to adverse childhood experiences (ACEs), such as abuse, neglect, or household dysfunction, significantly increases the risk of SUDs (Felitti et al., 1998). ACEs can disrupt brain development and increase vulnerability to addiction (Anda et al., 2006). Trauma, including intergenerational trauma, is strongly associated with SUD risk (SAMHSA, 2021). Trauma can lead to chronic stress and dysregulation of the stress response system, increasing susceptibility to addiction (Brewer et al., 2015).
Earlier age of first substance use is a significant risk factor for SUDs (SAMHSA, 2021). Adolescent brains are particularly vulnerable to the effects of substances, and early exposure can alter brain development and increase addiction risk. Individuals with SUDs often have co-occurring mental health conditions, such as depression or anxiety, or chronic health conditions, such as chronic pain (SAMHSA, 2021). These co-morbidities can exacerbate SUDs and make treatment more challenging.
The Evolving Substance Use Landscape
The substance use landscape is constantly evolving, with polydrug use becoming increasingly common (SAMHSA, 2023). Counterfeit pills containing fentanyl, sold through social media, pose a significant threat to youth (CDC, 2023). Additionally, the combination of opioids with non-opioid substances, such as xylazine and designer benzodiazepines, creates unique challenges for overdose reversal (Jones et al., 2023).
The Role of COVID
The social and economic impacts of COVID coupled with the systemic racism caused a significant rise in opioid fatalities in the Black community during and post COVID. Research published in JAMA showed the pandemic was associated with a drop in medical prescriptions for opioids and a recent study has shown that the sudden stopping of opioids increases the risk of suicide as it induces people to substitute illicit opioids like heroin and fentanyl (Warraich, 2022). A lack of the 4Ss (safety, security, stability, and survival) are associated with health and social consequences that perpetuate opioid use, overdose events, and detrimentally impact recovery efforts (Banks, 2022).
Illinois Overdose Statistics
According to the Illinois Department of Public Health (IDPH), in 2022, there were 3,239 overdose deaths in Illinois, a 10.3% increase from 2021. Of these deaths, 82% involved fentanyl, a powerful synthetic opioid, up from 78% in 2021. Cocaine was involved in 35% of overdose deaths in 2022, up from 29% in 2021. Methamphetamine was involved in 29% of overdose deaths in 2022, up from 22% in 2021. In 2022, there were 15,286 overdose reversals reported by EMS and hospitals to IDPH, and 3,153 community-driven reversals reported to the Illinois Department of Human Services (IDHS). Naloxone, an overdose-reversal medication, was used in 97% of overdose reversals in 2022 (IDPH, 2023).
Black individuals are disproportionately affected by overdose deaths in Illinois. In 2021, the overdose death rate for Black individuals was 37.5 per 100,000 people, compared to 18.6 per 100,000 people for white individuals. Overdose deaths are concentrated in certain areas of Illinois. In 2019, Cook County accounted for 40.64% of the total population but experienced 51.33% of the total opioid-related deaths, a proportion that increased in 2020. The next highest county accounted for 5.78% of total opioid-related deaths. According to the IDHS Division of Substance Use Prevention and Recovery's Grants to Prevent Prescription Drug/Opioid Overdose-Related Deaths federal application, the growing disparity in overdose deaths is driven by older adult Black populations of Chicago where rates of overdose death range from 56-112 per 100,000 people. In 2018, Black residents were 13.8% of the Illinois population but accounted for 39.09% of heroin and 24.47% of other opioid overdoses. In 2019, Black residents accounted for 44.9% of heroin fatal and non-fatal overdoses and 30.94% of other opioids fatal and non-fatal overdoses. From 2013 to 2019, there was an 182.8% increase in mortality among Black individuals in Illinois due to heroin and a 737.3% increase due to other opioids, mainly synthetic opioids.
Conclusion
Substance use disorders are complex health problems with a wide range of contributing factors and profound impacts on marginalized communities. Individual and social factors all interact to increase the risk of developing a SUD. Addressing these and their disparate impacts requires a comprehensive approach that includes evidence-based prevention and treatment strategies, reduced stigma, and policies that promote equity and opportunity.
Overdose deaths in Illinois continue to rise, with fentanyl being a major contributing factor. The State has implemented various policies to address the overdose crisis, yet continued efforts are needed to reduce overdose deaths and improve the health and well-being of people who use drugs within the context of a rapidly changing illicit drug supply.
Shifts in Black male age distribution are driving overdose mortality changes. Among Black men in their 30s and 40s, fatal overdoses will increase through 2025. Among younger and older men, overdose deaths are projected to decline (Harris, 2023). Among Black men aged 31-47 years, overdose deaths in 2025 are expected to increase by 440 or 11% (95% CI=8%, 14%) relative to 2020. By contrast, overdose deaths among younger Black men aged 19-30 years are expected to decline by 160 or -9% (95% CI= -15%, -5%). Among older Black men aged 48-64 years, overdose deaths are also expected to decline by 330 or -7% (95% CI= -10%, -4%) (Harris, 2023).
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