Urban, individuals of color are impacted by fentanyl-contaminated heroin

Abstract

The present phase of the overdose epidemic is characterized by fentanyl-contaminated heroin, particularly in the eastern United States (U.S.). However, there is little research examining how changes in drug potency are affecting urban, racial minority individuals who have been affected by both the “old” epidemic of the 1940s through 1980s, as well as the “new” present day epidemic. A focus on the drug using experiences of racial minorities is needed to avoid perpetuating discriminatory responses to drug use in communities of color, which have characterized past U.S. policies. This qualitative study was conducted from March through June 2018 to examine recent experiences of urban, individuals of color who inject drugs to assess the impact of the current overdose epidemic on this understudied population. Interviews were conducted with 25 people who reported current injection drug use. The interviews were transcribed and analyzed using a general inductive approach to identify major themes. Fifteen of 25 participants reported experiencing a non-fatal overdose in the past two years; eight suspected their overdose was fentanyl-related. Likewise, 15 had ever witnessed someone else overdose at least once. Overdoses that required multiple doses of naloxone were also reported. Participants employed several methods to attempt to detect the presence of fentanyl in their drugs, with varying degrees of success. Carrying naloxone and utilizing trusted drug sellers (often those who also use) were strategies used to minimize risk of overdose. Contaminated heroin and increased risk for overdose was often encountered when trusted sources were unavailable. This population is suffering from high rates of recent overdose. Removal of trusted drug sources from a community may inadvertently increase overdose risk. Ensuring access to harm reduction resources (naloxone, drug testing strips) will remain important for addressing ever-increasing rates of overdose among all populations affected.

Introduction

Rates of opioid use and overdose in the United States (U.S.) continue to increase. Drug overdose deaths in the U.S. have been described as an epidemic, with rates increasing four-fold between 1999 and 2017 to an alarming 72,000 overdose deaths occurring in 2017 alone. This number is higher than the peak number of deaths from AIDS, gun violence, and car accidents (National Center for Health Statistics, 2018; Sanger-Katz, 2018). The current overdose epidemic has been characterized as having three intertwined phases, the most recent of which, beginning in 2013, includes an increased prevalence of heroin contaminated with synthetic opioids, predominantly fentanyl (Dasgupta, Beletsky, & Ciccarone, 2018). Fentanyl has been linked to a surge in overdose deaths due both to its high potency and the fact that it is frequently cut into heroin without users’ knowledge (Amlani et al., 2015; Carroll, Marshall, Rich, & Green, 2017; Dasgupta et al., 2018). Rates of heroin overdose in the U.S. are currently increasing at 31% (95% confidence interval [CI] = 27, 35) per year for white individuals and 34% (95% CI = 30, 40) for Black individuals (Alexander, Kiang, & Barbieri, 2018). Less reliable national surveillance data is available concerning racial differences in synthetic opioid overdose, however emerging evidence from the local and state levels have shown increasing mortality among Black Americans (Peñaloza, 2018). Among all races, national rates of fentanyl-related fatal overdose spiked 540% between 2013 and 2016 (Centers for Disease Control & Prevention, 2018; Katz, 2017).

Fentanyl-related overdose is on the rise nationwide but is a particularly pressing problem in the eastern United States. The eastern U.S. heroin market consists largely of white powder heroin, which is easier to cut with fentanyl due to its color and consistency compared to western black tar heroin (Ciccarone, 2009, 2017). Fentanyl is easier to produce than heroin, can be smuggled in small batches, and offers high profit margins for sellers. These characteristics have contributed to its increased prevalence in U.S. drug markets (Rothberg & Stith, 2018). Fentanyl seizures in the U.S. increased by 426% from 2016 to 2017 and are strongly correlated with observed increases in synthetic opioid overdoses (Ciccarone, 2017). In North Carolina (NC), the rate of overdose deaths doubled from 2010 to 2016 (N.C. Division of Public Health, 2017). The Centers for Disease Control (CDC) predicts an increase in the number of overdose deaths in NC of 14.5% from 2017 to 2018. This is the fourth highest predicted increase among all US states (Centers for Disease Control & Prevention, 2018). NC experienced an estimated 98.8% increase in fentanyl-involved overdose fatalities from 2015 to 2016 (Miller & Winecker, 2017).

Popular narratives about how the overdose epidemic came about and who it is affecting have predominantly focused on white, rural individuals (Cicero, Ellis, Surratt, & Kurtz, 2014; Netherland & Hansen, 2016; Quiñones, 2015). Per this narrative, trajectories into substance use often began with an opioid prescription for pain management, evolved into opioid use disorder, and resulted in a shift to regular heroin use once policy changes restricted access to that prescription supply. Less attention, however, has been given to the substance use trajectories of urban populations and people of color (Shihipar, 2019). Although white Americans die from opioid-related causes in the highest numbers each year, opioid-related death rates have doubled among Black Americans since 2000 (James & Jordan, 2018). Opioid-related deaths have markedly increased among Black Americans since the fentanyl-fueled phase began in 2013. In 2017, 12% of all opioid-related overdose deaths were among Black individuals – up from 8% in 2013 (Kaiser Family Foundation, 2019). This trend is particularly pronounced in urban areas. According to recent estimates, the rate of drug overdose death among urban Black individuals is 22.7% compared to 6.7% for rural Black individuals. In Washington, D.C., more than 80% of opioid overdose deaths are among Black people, which local medical personnel have linked to fentanyl-contaminated drugs (Peñaloza, 2018).

The whitewashed portrayal of the overdose epidemic is consistent with the history of drug discourse in America, which criminalizes minority substance use and medicalizes white substance use (James & Jordan, 2018). Following World War II, young Black and Latino Americans living in cities became the largest demographic of heroin users (Schneider, 2008). This surge of heroin use among Black individuals was initially linked to “hipster” subculture in jazz clubs, which portrayed heroin use as a socially desirable behavior and facilitated its spread to inner city youth. However, government officials and media outlets were quick to link illicit drug use to rising crime rates in inner cities, exacerbating racial tensions and declaring drug use a menace to American youth (Schneider, 2008). A moral panic followed, resulting in punitive responses, such as mandatory minimum sentencing that set the precedent for America’s ongoing War on Drugs (Schneider, 2008). Despite gentler policy responses to the current epidemic, racial disparities in outcomes persist. Black individuals are still arrested at higher rates for heroin offenses and are undertreated for substance use disorders in comparison to whites (James & Jordan, 2018). Popular discourse regarding the “new” [white] heroin epidemic serves to marginalize Black communities by ignoring a long history of racially discriminatory responses to similar drug epidemics and minimizing their current need for public health resources and programming (James & Jordan, 2018).

Therefore, in the current study, we explored the experiences of a sample of urban, mostly Black individuals who inject drugs. Little research has explored how the current, fentanyl-fueled phase of the overdose epidemic has entered into and affected minority populations. This knowledge is necessary for informing tailored intervention efforts and reducing the potential for unequal allocation of resources to populations in need.

Participants were recruited from May and July 2018 through one of two strategies: (1) on-site at syringe access programs in Durham, NC, and (2) by referral from syringe exchange staff or other participants. To be eligible to participate, participants met the following criteria: self-reported current (within the last month) injection drug use; age ≥18 year at study enrollment; able to understand and speak English or Spanish; and able to provide verbal informed consent. All of the participants had previously accessed local harm reduction services where they are able to access syringes and, more recently, fentanyl test strips. Consenting participants were interviewed (by R.H. and L.B.R.) and were offered $50 for completing the interview. Interviews were administered by phone or in a private room at a community-based venue convenient for the participant (e.g. the public library, a community center). Participants were asked about pathways to injection drug use, experience with overdose, use of harm reduction services, experiences with illicitly-manufactured fentanyl, contact with law enforcement, previous incarceration, and HIV risk and prevention strategies. All interviews were digitally recorded and professionally transcribed. This protocol was approved by the University of North Carolina Institutional Review Board.

A general inductive approach was used for analysis (Thomas, 2006). A preliminary codebook was developed based on the content of the interview guide. Two separate coders, B.R. and L.B.R., coded 6 of the 25 transcripts in order test the coding scheme and establish intercoder reliability. The two coders met following coding of transcripts 1–3 to compare coding and resolve areas of discrepancy. At this time, inductive codes were added to capture additional emerging themes of interest. This process was repeated using the revised codebook for transcripts 4-6. Following initial coding and finalization of the codebook, B.R. completed coding of all remaining transcripts. Data was summarized and organized by emerging themes using NVivo 11 (QSR International, Burlington, Massachusetts, USA).