Statewide, drug overdoses are at an all-time high. Although absolute counts suggest the highest burden among the non-Hispanic White population, overdose rates showing impact per total populations indicate greater burden on some historically marginalized populations (HMPs), particularly American Indian communities (AI). To prevent further harm to HMPs and work toward health equity in the overdose epidemic, addressing this disproportionate burden among AIs must be prioritized. Recommended strategies include providing culturally appropriate, community-driven approaches to improving access to effective overdose prevention, harm reduction, treatment, and social support services.
A previous analysis conducted by the North Carolina Division of Public Health (NCDPH) found that AIs in North Carolina are disproportionately impacted by fatal overdoses and injection-drug-related infections [1]; in an unpublished update of that analysis, completed by epidemiologists at NCDPH in August 2021, the data show that fatal overdose rates are increasing faster in HMPs, specifically in non-Hispanic Black and AI communities. In 2019, the most recent year with complete data included in the updated analysis, AIs had an overdose death rate 1.6 times higher than that of non-Hispanic Whites (43.3 and 27.4 per 100,000, respectively). It’s worth noting that in the general population, men have higher overdose death rates, but among AI populations, men and women have similar rates. Additionally, trends in the drug type involved in overdoses vary across racial/ethnic groups, indicating that harm reduction and overdose prevention strategies need tailoring to be effective and relevant in different communities; the more recent data show that among AI populations, rates of overdose involving illicit opioids and cocaine are higher and increasing faster than rates of overdoses involving prescription medications. To better address the changing landscape of this epidemic, the North Carolina Opioid and Substance Use Action Plan (OSUAP 3.0) was launched in June 2021. The OSUAP 3.0 updates the Opioid Action Plan to include a broadened focus on substances beyond opioids and centers equity and lived experiences. As the plan notes, centering equity starts by acknowledging systems that have disproportionately harmed HMPs and ensuring that the strategies to address the overdose epidemic are led by those closest to the issue [2].
HMPs have been systematically marginalized through decades by a criminalized response to substance use. This has taken root in critical systems, including education, employment, housing, child welfare, immigration, and public benefits [3]. Additionally, centering people with lived experience is key to ensuring the most cutting-edge, culturally appropriate programming to prevent overdose and reduce the harms of substance use. The drug market and methods of use are continually changing; often by the time the data reflect these trends, people who use drugs have known about the changes for months and even years and have already adapted harm reduction strategies to reflect these changes. To stay the most up to date about trends and needs, we must center people with lived experience in our work, including people currently using drugs. This continued analysis of the impacts of the overdose epidemic on AI communities in North Carolina has involved ongoing conversations between state agencies and tribal leaders, including members of the North Carolina American Indian Health Board and the Tsalagi Public Health Syringe Exchange Program.
The role of syringe services programs (SSPs) in effectively reaching HMPs cannot be overstated. Since legalization in 2016, North Carolina SSPs have provided a variety of social and health services for people who use drugs, often serving as the primary avenue for meeting their health needs. SSPs offer sterile syringes and disposal services to remove hazards from the community, prevent sharing and reuse of syringes, provide wound care, distribute naloxone, provide referrals to mental health and substance use disorder treatments, administer HIV and other STI tests, and offer many other wraparound services. SSPs provide a way to include culturally appropriate prevention strategies in statewide efforts to reduce substance-use-related morbidity and mortality. SSPs have also played a critical role during the COVID-19 pandemic, which has changed health behaviors and affected access to health care services nationwide. During the pandemic, alcohol and substance use has increased [4], more US adults are reporting anxiety or depression symptoms [5], and emergency department (ED) visits for overdose have increased [6]. Amid this increased need, many SSPs have provided and expanded critical health services for overdose prevention, and were deemed essential operations in North Carolina [7].
Provisional state and national data show that 2020 had the highest number of overdose deaths ever recorded [8, 9]. While 2020 North Carolina death data are not yet finalized, ED data show a 22% increase in 2020 visits for overdose statewide, and in communities with large AI populations this increase was often higher; ED visits for overdose increased 80% in 2020 in Robeson County, which has a large AI population [8]. Numerous studies have found that COVID-19 incidence and mortality are higher among AIs [10–12]; this disproportionate impact, compounded by the long-standing impacts of the overdose crisis—now an epidemic within a global pandemic— highlights the immense need for dedicated resources for culturally specific, tailored prevention, harm reduction, treatment, recovery, and social supports like housing and employment services in AI and other long-standing marginalized communities.
Acknowledgments
The authors thank staff at the Tsalagi Public Health Syringe Exchange Program, members of the North Carolina American Indian Health Board, and other tribal leaders across the state for their collaboration and commitment to overdose prevention. We also wish to thank North Carolina Department of Health and Human Services staff and partners for their work developing and updating the Opioid and Substance Use Action Plan to provide a framework for the work in our state. A debt of gratitude is owed to the staff who support the North Carolina Safer Syringe Initiative and SSPs across the state for their tireless efforts to improve the lives of people who use drugs, especially in the midst of a global pandemic.
Finally, we acknowledge the tremendous efforts of the North Carolina Office of the Chief Medical Examiner and the North Carolina State Center for Health Statistics in processing and making the North Carolina death data available for injury surveillance, and the Communicable Disease Branch HIV/STD/Viral Hepatitis Surveillance Unit for collecting, analyzing, and disseminating infectious disease surveillance data.
Financial support: This work was supported in part by the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. M.E.C., M.A.S., A.R.P., S.P., and the Injury and Violence Prevention Branch, Division of Public Health, North Carolina Department of Health and Human Services receive support from the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
Disclosure of interests. R.A.B. serves as a scientific editor for the North Carolina Medical Journal, editing articles for the original research section of the publication. He assisted in the planning of this issue and reviewed each article. All articles were edited by Editor-in-Chief Peter Morris and Managing Editor Kaitln Phillips. No further interests were disclosed.
- ©2021 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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