Overdose Deaths and Acute Hepatitis Infections among American Indians in North Carolina

Conclusions

Frequently, articles examining the racial and ethnic disparities of the overdose epidemic focus primarily on the outcomes of whites compared to blacks, and sometimes Hispanics. [1-3, 12]. While there are certainly important historical factors contributing to the disparate outcomes these racial/ethnic groups are experiencing, our analysis emphasizes the immense need to broaden the scope of prevention and response efforts to include AIs in addition to other racial and ethnic populations. During the 17-year study period for which death data was available (2000-2016), overdose death rates among whites were higher than rates among Asians and Hispanics across all substance types, and whites had higher rates than blacks across all substance types except cocaine. However, our results show that AIs had rates as high as or higher than white populations for every substance type, except heroin.

While the literature may suggest that the current drug epidemic is primarily affecting white men, the data show that AIs in North Carolina are also significantly impacted and have higher rates of unintentional medication and drug overdose than the overall state rate. These results suggest a need for overdose prevention interventions tailored to the AI populations in our state. These interventions should take care to include both AI men and women since they have similarly high rates of overdose, unlike the overall North Carolina population rates, which show men having much higher rates of overdose than women.

Our analysis also revealed that over the last 5 years (2012-2016), 50% of AI unintentional medication and drug overdose deaths occurred among residents of Robeson County, where 44% of the state's AI population resides. Over 53,000, or 39%, of Robeson County residents are AIs, the majority of whom likely belong to the Lumbee Tribe of North Carolina. Though recognized as a tribe by the state of North Carolina, the Lumbee Tribe does not receive full federal recognition and therefore does not have the same access to health care and other benefits afforded to federally recognized tribes [13]. Due to the large population of AIs and the high number of overdose deaths, we encourage prioritizing AI overdose prevention efforts in Robeson County.

Rates were calculated whenever possible to ensure comparability between racial/ethnic groups. However, when examining one specific race/ethnicity and one substance type it was necessary to suppress some rates even when combining multiple years of data. It is worth noting that although numbers were not always high enough to report a rate, the frequencies of unintentional overdose across each race/ethnicity and each substance type did increase throughout the study period. In 2016, based on guidance from CDC, the case definition for acute HCV was updated to include both confirmed and probable cases; therefore, comparisons before and after this change should be made with caution [10]. Another limitation of our study was the number of cases of acute HBV and HCV infection with missing data, as 14% of HBV and 5% of HCV cases from 2012 to 2016 had an unknown race/ethnicity. Additionally, the CDC estimates that both acute HBV and HCV are underreported in the United States across all races and ethnicities [10]. While only 0.1% of unintentional medication and drug overdose deaths from 2000 to 2016 had an unknown race/ethnicity, race and ethnicity data recorded on death certificates are frequently provided by family members and are difficult to verify and validate independently, often leading to an underreporting of AI deaths. However, the limitations found in death certificate data are thought to be minimal for most other racial and ethnic groups [14, 15]. This analysis focused on all unintentional medication and drug overdose deaths, but only included the specific subcategories of commonly prescribed opioids, heroin, other synthetic narcotics, and cocaine. Future analyses should expand to include additional subcategories of medication and drug overdose, like benzodiazepines and prescription stimulants, as deaths from these substances may also vary across races and ethnicities. Broad movement toward illicit drugs, which are more likely to be injected than pharmaceutical drugs, necessitates further investigation of associated IDU health outcomes. Future work may benefit from racial/ethnic analyses of outcomes including, but not limited to, skin infections, endocarditis, and HIV infections.

While AIs in North Carolina are still most affected by unintentional overdose deaths due to commonly prescribed opioids, overdose rates involving heroin and other synthetic narcotics are also increasing, mirroring trends emerging across the country [16]. Our results show that rates of newly diagnosed acute HBV and HCV are increasing statewide, and AI populations have rates of acute HCV over 3 times as high as the rate in the overall North Carolina population. These increased rates of acute HBV and HCV infection are likely linked to increased IDU within this population. There were no cases of acute HBV among AI in 2012, and in 2016 50% (N = 1) reported exposure through IDU; 0.0% of acute HCV cases among AI in 2012 reported IDU compared to 77.8% (N = 7) in 2016. The increase in reported IDU among AI with acute HBV and HCV highlights a need for inclusion of culturally appropriate prevention strategies to reduce substance use-related morbidity and mortality. This analysis is timely, as North Carolina works to adopt recommendations from the state Opioid Action Plan, developed in 2017. Though AIs are not named in the plan, the NC OAP identifies priority areas that can be implemented in culturally relevant ways, requiring further attention to how different racial/ethnic groups experience and respond to the overdose crisis. One recommendation is for the establishment of syringe exchange programs (SEPs), evidence-based interventions that help mitigate the harms associated with IDU and can embrace and respond to local trends and cultural practices. After the legalization of SEPs in July 2016 (GS 90-113.27), NC DHHS and community partners established the North Carolina Safer Syringe Initiative (NCSSI). NCSSI supports the development and operation of syringe exchange and harm reduction programs across the state through technical assistance and strategic partnerships.

Beyond providing unused syringes and supplies that reduce the health harms and risks associated with IDU, exchanges also provide overdose prevention education and resources, including naloxone training and distribution; education on preventing bloodborne disease infection and substance use disorder (SUD); and connections to mental health and SUD treatment, including medication-assisted treatment (MAT), as well as other social and medical services. People who inject drugs are at significant risk of HCV infection, but may be unwilling or unable to share risk factors with traditional health care providers [17]. Dedicated drug user health services that reduce stigma and judgment enable access to HCV prevention and care. Engagement through SEPs with people who inject drugs promotes information sharing and treatment for injection-related and general health conditions. Overdose prevention, naloxone access, and other community health services offered by SEPs are also available to people affected by or involved with drug use in different ways, including friends, family members, and partners of people who use drugs. A recent needs assessment of AI injection drug users in Montana revealed that 98% of participants would take advantage of a harm reduction program and 94% said they preferred a peer model for delivery of the program, highlighting the need to establish tribal SEPs as a method for providing culturally appropriate care to a population in our state that has been heavily impacted by the overdose epidemic [18].

In April 2017, NCSSI began working with EBCI located in Western North Carolina. Recent increases in acute HCV infection rates, incidence of needle-stick injuries, and improperly disposed syringes drove interest in establishing a tribal SEP. EBCI Public Health and Human Services (PHHS) held internal planning meetings to discuss program development, assignation of duties, and the integration of SEP services into a reorganized PHHS structure. During this process, NCSSI provided information on program establishment, EBCI participation in state reporting requirements, and existing tribal harm reduction programs. EBCI PHHS received preliminary support for the development of a program from the Tribal Council in June 2017 and received full approval in August 2017. The Tsalagi Public Health Syringe Exchange Program at PHHS opened in March 2018. In addition to SEP services administered by PHHS, SEPs in Macon and Buncombe counties have reported serving EBCI residents.

The establishment of tribal SEPs is only one of many strategies necessary to combat negative health outcomes associated with the overdose epidemic. Continued inclusion of AI communities across North Carolina is needed to develop interventions tailored to the needs of a population often overlooked by prevention efforts, despite high rates of hepatitis infection and unintentional overdose death. Coordination and prevention activities are an essential component of the NC OAP, the state's primary prevention tool. The NC OAP acknowledges that it is a living document, leaving room to revise strategies based on the changing landscape of the epidemic; leadership should therefore consider expanding the plan to directly address prevention and treatment strategies to reduce future morbidity and mortality among American Indians in North Carolina.