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Overdose mortality rates are at all-time highs and disproportionately impact non-Hispanic Black men (Khatri, Pizzicato, Viner, et al., 2021). There has been a 38 percent overall increase in overdose deaths for non-Hispanic Black men from 2018-2019, yet estimates vary from state to state (Larochelle, Slavova, Root, et al., 2021). Therefore, it is crucial to examine timely local data to inform community-driven harm reduction and overdose prevention services. Although factors associated with fatal opioid overdose have been explored, few studies have accounted for the potential moderating effects of nonfatal opioid overdoses (NFOO) and sociodemographic health disparities. We used emergency medical services (EMS) naloxone administration data and vital records to examine: 1) the frequency of NFOO to fatal drug overdose (FDO) events; 2) the duration between NFOO and FDO among decedents; 3) the specific hazard effect of demographic characteristics and repeated NFOO on drug-related mortality within the two years following NFOO.
Methods
Records of EMS naloxone administrations were used as a proxy for opioid overdose events occurring in Detroit, Michigan, between 01/01/2018-06/08/2019. State-provided vital records were used to determine FDO (ICD Codes X40-44; X60-64; X85; Y10-14) occurring before 06/08/2021. We selected adults who experienced a NFOO during the study period (N=2,810). Demographic measures included age, race (Black/non-Black), and sex (male/female). Number of NFOOs within the study period and FDO (yes/no) within two years following initial NFOO were also utilized. We conducted bivariate analyses (α=.05) and a Cox proportional hazard model using 95% confidence intervals (CI).
Results
Of the 2,810 overdose survivors, 18.4% (n=516) had at least one additional NFOO within the study period, the mean additional NFOOs totaling 0.32 (SD=.881; range=0-11). Within two years of the NFOO, 6.2% (n=174) died by drug overdose, with a mean duration between NFOO and FDO of 286 (SD=211.318) days. Among decedents, 27.0% (n=47) had experienced at least one additional NFOO in the two years prior, with mean additional NFOOs totaling 0.45 (SD=.989; range=0-7). After controlling for age, sex, and race, the hazard of FDO increased for each additional NFOO experienced during the study period (HR=1.141, 95%CI=1.005-1.295). All other factors held constant, being Black (69.0%, n=1938) decreased hazard of FDO (HR=.616, 95%CI=.434-.875), even while a greater proportion of Black individuals (19.9%, n=386) experienced multiple NFOOS than non-Black people (14.8%, n=127), X2(1)=10.633, p=.001, and died by causes other than drug overdose at a rate more than double that of non-Black people (14.5%, n=281 vs 5.6%, n=48), X2(1)=45.776, p<.001). Black individuals were older on average than non-Black (56.4 years, SD=14.277 vs 39.8, SD=12.893), t(-29.265, 2790)=2.734, p<.001. No significant effects were found based on sex.
Conclusions and Implications
Findings indicate a high risk of FDO in the two years following a nonfatal opioid overdose and a greater risk of repeated nonfatal overdose. Non-Hispanic Black individuals’ mortality was driven by non-overdose causes, despite being, on average, older in age and more likely to experience multiple nonfatal overdoses. Widespread implementation of overdose prevention and general medical care is warranted to curb NFOO and all-cause mortality among non-Hispanic Black individuals.