NC Medical Journal -- BACKGROUND Like the rest of the nation, North Carolina is experiencing the worst drug crisis in United States history, as deaths related to medication and drug overdoses are at an all-time high. Although the absolute numbers of deaths are highest among white populations, American Indians (AIs) experience disproportionally high rates.

METHOD Using death certificate data, death rates due to unintentional medication and drug overdose were calculated for various races and ethnicities. Acute hepatitis B (HBV) and acute hepatitis C (HCV) rates were also calculated across racial and ethnic groups using data from the North Carolina Electronic Disease Surveillance System.

RESULTS After adjusting for population size, AIs have as high or higher overdose death rates for all types of drugs except heroin, compared to other racial and ethnic groups. During the most recent 5 years of data (2012-2016), the highest rate of acute HCV infection occurred among AIs.

LIMITATIONS Race/ethnicity data recorded on death certificates is often provided by family members and is difficult to verify independently. Another potential limitation is use of small numbers to calculate rates. Additionally, HBV and HCV are thought to be underreported.

CONCLUSION Overdose death rates and rates of communicable diseases associated with injection drug use among AIs residing in North Carolina are as high as or higher than the overall North Carolina population. It is important to recognize and address these differences and provide prevention, harm reduction, and treatment services to all groups being impacted by the overdose epidemic.
North Carolina, like the rest of the nation, is experiencing an overdose epidemic that is severely impacting both morbidity and mortality across the state. To effectively combat the overdose epidemic, it is necessary to understand which populations are most affected by substance use-related morbidity and mortality. The impact of the opioid epidemic on white populations in the United States has received much attention. Headlines suggest that the current drug epidemic has garnered national responsiveness because, unlike other drugs, opioids, including heroin, are killing whites at higher rates than other races/ethnicities. This has resulted in a decrease in the life expectancy of US whites [1-3]. Despite national focus on this crisis, the impact of overdose deaths on minority populations, especially American Indians (AIs), is underreported.

It is critical for both federal and state governments to understand the burden of the opioid epidemic on special populations, like AIs. In June 2017, the North Carolina Department of Health and Human Services (NC DHHS) released the North Carolina Opioid Action Plan (NC OAP), a document that outlines multiple comprehensive strategies to combat the overdose epidemic in North Carolina. The plan has several focus areas to tackle the drug crisis including creating a coordinated infrastructure, reducing the oversupply of prescription opioids, reducing diversion of prescription drugs and the flow of illicit drugs, increasing community awareness and prevention, increasing availability of naloxone, and expanding access to treatment and care [4]. The NC OAP details numerous actions to be led by multiple state and local agencies and partners across North Carolina and outlines 13 key metrics for tracking North Carolina's progress toward reducing substance use-related morbidity and mortality. The NC OAP highlights the needs of special populations like pregnant women and justice-involved persons; however, missing from the plan is any mention of the burden of this epidemic on AI populations in North Carolina.

According to 2016 US Census estimates, North Carolina has the 6th largest population of AIs in the country, and the largest population of any state east of the Mississippi River [5]. In 2016 there were over 120,000 AIs living in North Carolina, accounting for 1.2% of the state's total population [5]. There are 8 AI tribes recognized by the state of North Carolina: the Eastern Band of Cherokee (EBCI), Coharie Tribe, Haliwa-Saponi Indian Tribe, Sappony Tribe, Lumbee Tribe of North Carolina, Meherrin Indian Tribe, Occaneechi Band of the Saponi Nation, and Waccamaw-Siouan Tribe. EBCI is the only federally recognized tribe, and the only tribe served by the US Indian Health Services [6]. In order to better understand the impact of the overdose epidemic on the AI population in North Carolina, 2 key metrics from the NC OAP were chosen for further analysis: unintentional overdose deaths and hepatitis infections. These metrics were chosen because they address elements of both substance use-related morbidity and mortality and provide race and ethnicity variables in each dataset.

From 2000 to 2016, unintentional medication and drug overdose deaths increased 441% in North Carolina. Historically, most of these deaths were due to prescription opioid analgesics (hydrocodone, methadone, oxycodone), but in recent years heroin and other synthetic narcotics, like illicitly manufactured fentanyl and its analogues, have been involved in an increasing number of deaths. North Carolina is also experiencing a growing number of deaths involving cocaine [7]. Increasing rates of new infections of bloodborne illnesses are additional consequences of the opioid epidemic as nearly 55% of hepatitis C cases can be attributed to injection drug use (IDU) [8]. Rates of acute hepatitis B (HBV) and acute hepatitis C (HCV) have been rising in North Carolina, and rates of both acute HBV and HCV in the state have been higher than the national rates since 2008. In 2016, North Carolina's rate for acute HBV infection was 1.5 cases per 100,000 residents, while the US rate in 2016 was 1.0 cases per 100,000. North Carolina's 2016 rate of acute HCV infection was 1.8 cases per 100,000, higher than the 2016 US rate of 1.0 cases per 100,000 [9, 10]. While the burden of the overdose epidemic is felt well beyond these 2 metrics, death and acute HBV and HCV infections were the focus of this analysis as these data help quantify the direct impacts of the changing landscape of the overdose epidemic.

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Methods
North Carolina State Center for Health Statistics (SCHS) Vital Records death certificate data were used to identify unintentional medication and drug overdose deaths with an International Classification of Diseases, 10th Revision (ICD-10) primary cause-of-death code of X40-X44 (eg, medication or drug). Deaths involving specific drugs were identified using underlying cause-of-death codes for cocaine (T40.5); commonly prescribed opioids, including medications like oxycodone, hydrocodone, codeine, and many others (T40.2 or T40.3); other synthetic narcotics, primarily fentanyl and fentanyl analogues (T40.4;); and heroin (T40.1). All death data were limited to North Carolina resident deaths, and mortality rates were calculated by drug type involved, sex, age group, and race/ethnicity as stated on the death certificate for the study period of 2000-2016. Rates were also calculated over 5-year periods to examine trends over time.

Acute HBV and HCV cases from the last 5 complete years of data (2012-2016) were pulled on June 1, 2017, from the North Carolina Electronic Disease Surveillance System (NC EDSS), a web-based health surveillance and reporting system. NC EDSS is used by the Division of Public Health, the state's 85 local and multi-county district health departments (LHDs), and 7 HIV/STD Regional Offices. Following Centers for Disease Control and Prevention (CDC) guidelines for hepatitis surveillance, confirmed cases of acute HBV and HCV met both the clinical and serologic case definitions [9, 10]. Confirmed cases were combined to calculate overall rates and rates by race and ethnicity. Infection risk assessment data were also available in NC EDSS through the LHDs' investigation of new acute HBV and HCV infections. Overall population trends and the percent of HBV and HCV cases with exposure through IDU were calculated by race and ethnicity.

Both mortality and infection rates were calculated using the population estimates from the National Center for Health Statistics' US Census data [11]. Rates were not calculated for multiple race or unknown race and ethnicity groups due to the lack of overall population data. AI, Asian, white, and black populations are all non-Hispanic. Asian populations include both Asians and Pacific Islanders, and AI populations include both AIs and Alaskan Natives. All rates are reported as per 100,000 North Carolina residents and are suppressed when there are fewer than 5 cases. This analysis was conducted using SAS 9.4, and mapping was completed in ArcGIS 10.3.1.
 
Results
Overdose Deaths
From 2000 to 2016, the rate of deaths due to unintentional medication and drug overdose among AIs was 1.3 times greater than the rate among the total North Carolina population—12.2 and 9.6 cases per 100,000 residents, respectively. Among the total North Carolina population, overdose death rates were nearly twice as high among men (12.3 per 100,000) as among women (6.9 per 100,000). However, AI men and women had similar overdose rates of 12.6 per 100,000 among men and 11.8 per 100,000 among women. The highest rates of fatal overdose for both the total North Carolina population and AIs occurred among those aged 45-54, and rates in this age group were higher among AIs. Rates of overdose by sex and age for both populations are presented in Figure 1.

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FIGURE 1.American Indian Unintentional Medication and Drug Overdose Rates per 100,000 North Carolina Residents Compared to the Total North Carolina Population Unintentional Medication and Drug Overdose Rates per 100,000 Residents, by Sex and Age, 2000-2016

 
Overdose death rates during the study period were calculated by substance type across white, black, AI, Asian, and Hispanic populations. AIs and Whites had equal rates of overall unintentional medication and drug overdose deaths (12.2 per 100,000). Across all races and ethnicities, AIs had the highest overdose rates among deaths involving cocaine (3.4 per 100,000). AIs and whites had equally high rates of fatal overdose involving other synthetic narcotics (1.9 per 100,000). Although whites had the highest rate of deaths involving commonly prescribed opioids (6.6 per 100,000), AIs had a similarly high overdose rate (6.1 per 100,000). Table 1 provides all overdose death rates by substance type, race, and ethnicity.

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TABLE 1.Unintentional Overdose Rates per 100,000 NC Residents, by Drug Type, Race and Ethnicity, 2000-2016a

 
Trends over 5-year time periods showed increased rates of unintentional overdoses involving commonly prescribed opioids, heroin, other synthetic narcotics, and cocaine within the North Carolina AI population. Among the specific substance types, deaths involving commonly prescribed opioids saw the most dramatic increase, with a rate of 3.7 per 100,000 from 2002 to 2006 increasing to a rate of 8.5 per 100,000 from 2012 to 2016. Rates of deaths involving commonly prescribed opioids were highest across all 3 5-year time periods. Figure 2 depicts the change in AI overdose rates over time for each substance type.

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FIGURE 2.American Indian Unintentional Overdose Rates per 100,000 North Carolina Residents by Drug Type over 5-Year Time Periods, 2002-2016

 
Frequencies were calculated by residence county of AI unintentional medication and drug overdose decedents during the most recent 5-year time period (2012-2016). Fifty percent (N = 46) of AI unintentional overdose deaths occurred among individuals residing in Robeson County. AI overdose deaths also occurred among residents of Jackson, Cumberland, Hoke, Scotland, Guilford, Durham, Forsyth, Moore, Sampson, Swain, Brunswick, Franklin, Gaston, Halifax, Harnett, Lee, Lincoln, Mecklenburg, Pender, Transylvania, and Wake counties but with much lower numbers (less than 8 cases for any listed county). In most instances, the numbers were too low to calculate a stable rate for accurate comparability across counties.


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