By Aara Ramesh
In the face of the real and present danger posed by Covid-19, the opioid crisis, America’s long-standing other epidemic has fallen under the public radar, though it continues to ravage large swathes of society. Experts say that, as with most socioeconomic problems, communities of color — particularly Indigenous ones — have been disproportionately affected by the nationwide opioid crisis.
The existing problem was, in a way, both exacerbated and mirrored by the Covid-19 pandemic. Overall, recent provisional data from the CDC revealed a nationwide surge in overdose deaths during the pandemic. Per this data, deaths from drug overdoses increased 30% between 2019 and 2020 across the country. It marked the worst annual death toll recorded by the government since the start of the opioid epidemic in the 1990s.
Much like with the opioid epidemic, the nation’s largest Indigenous tribes suffered some of the country’s highest per capita rate of Covid-19 infections. This strained an already under-resourced healthcare system, and compounded the harmful impact of other crises. In today’s piece, we take a look at how and why the opioid epidemic was so devastating for Indigenous communities, and what that meant for them in the context of the Covid-19 pandemic.
Native Americans And Opioid Addictions
Some estimates suggest that Native Americans are at least twice as likely as the general population to become addicted to drugs and alcohol. They are also around three times more likely to die of a drug overdose. Native Americans had the highest rates of overdose deaths in 2003–2013 from prescription painkillers and illicit opioids among all racial and ethnic groups, per data from the CDC. The rate of overdose deaths among Native peoples has increased almost six times since 2000, also faster than seen with any other group.
Analysis by the Washington Post concluded that between 2006 and 2014, “Native Americans were nearly 50 percent more likely to die of an opioid overdose than non-natives.” Per the Post’s reporting, at the peak of the opioid epidemic in the mid-2010s, the rates of fatal overdoses among Native Americans were on par with those seen in Appalachia, which houses some of the communities most crippled by drug addictions.
One 2014 study by the National Institute on Drug Abuse found that “the use of heroin and of the widely abused opioid painkiller OxyContin by American Indian 12th-graders was about double the national average.” Nationally, the rate of fatal drug overdoses is about 12 out of 100,000 for white people and around 11 among Black people; the rate among Native Americans in the state of Washington is at 29.
In the Cherokee Nation alone, opioid-related fatal overdoses more than doubled in the eleven-year span between 2003 and 2014. The Nation estimates they lost at least 350 members out of their total population of around 375,000 over that period. Per a lawsuit filed by the Cherokee Nation, “the tribe logged 10 admissions to drug treatment centers and 32 emergency room visits.”
For context, Native Americans make up only 2% of the U.S. population. What’s worse, it is quite likely that overdose deaths within Tribal communities were under-reported and undercounted. Further, as a result of the epidemic, the social infrastructure was completely overwhelmed by the opioid epidemic, straining Tribal medical, welfare, law enforcement, and foster-care systems.
Why Are Native Communities So Badly Affected?
The factors behind the higher rates of addiction within Native communities are manifold. Some tribal leaders and health experts attribute the high rates of opioid addictions within Native communities to the fact that more prescription pills were being shipped to Tribal lands than almost anywhere else in the country. This could have been for a number of reasons, they say. One is that Native American tend to suffer more injuries than the average person from working in labor-intensive industries like farming, logging, and fishing.
In addition, many Native Americans living on and off reservations lack adequate access to healthcare, mental health resources, and addiction recovery services. Their communities are often more physically isolated, smaller in size, and located in rural areas. This affects the healthcare infrastructure on a serious level, and results in a lack of nearby long-term, non-pharmacological treatment options for pain and injuries.
As sovereign nations, Tribes are responsible for their members’ healthcare and social service needs, the funding for which largely comes from their tribal revenue. Tribes, however, are more likely to be under-resourced, putting them at a distinct disadvantage when it comes to being able to best care for citizens.
On another level, however, it is important to note the effects that Social Determinants of Health (SDH) have on Native peoples. SDH are the “complex, integrated, and overlapping social structures, policies, and economic systems” that lead to health inequities. These could be physical like poor transportation and poor housing, or could be more abstract, like gender inequality, poverty, and structural racism.
People who don’t have a steady income may turn to drug use to cope; not having shelter may lead to or exacerbate an existing drug problem. Research has consistently shown that childhood experiences of alcoholism, drug abuse, and domestic violence in caretakers; physical and/or sexual abuse; emotional neglect; and a parent or family member being in prison are more likely to lead to a child developing behavioral or mental health problems in the future. It also makes them more susceptible to drug addictions.
Unfortunately, such “adverse childhood experiences” are all too common in Native American communities. Much of this, experts say, is the result of inter-generational trauma, which has been passed down over and over, and which has compounded over the course of the last several centuries. In addition, due to historical factors, rates of poverty, homelessness, and lack of education are also higher than the national average among Native American communities.
The Parallels And Intersections Between Covid-19 And The Opioid Epidemic
Nationally, the fatal overdose rates had actually started falling in 2018, but ramped up in the months leading up to the onset of the Covid-19 pandemic. In fact, the CDC estimated that the rate of opioid-related fatalities in Native Americans was slightly lower than that of white populations just before the pandemic last year.
However, the biggest spike in overdose deaths was noted in April and May 2020, just as unemployment rates were beginning to skyrocket, fear and stress were ramping up, and stringent lockdown measures were being introduced.
The primary drivers of the spike last year were singled out as illicitly manufactured fentanyl and other synthetic opioids, which are extremely potent and deadly. Many overdoses also involved stimulant drugs like cocaine and methamphetamine, which reduce a person’s tolerance of opioids, making the increasingly ubiquitous cocktail of drugs even more dangerous.
In fact, researchers have recently tried to shed light on the worrying surge in the number of deaths linked to methamphetamine, which rose roughly 180% between 2015 and 2019 across the country. Native Americans have the highest rates of methamphetamine use disorder of all racial and ethnic categories. Increasingly, street supplies of methamphetamines are cut with fentanyl. Researchers also found that behaviors are likely to be more risky when it comes to methamphetamine misuse, in terms of using needles to inject it and combining it with other drugs like fentanyl.
In the context of the pandemic, what is of particular concern is what happens when society returns to “the old normal.” Dr Mike Brumage, former director of the West Virginia office of drug control policy, told The Guardian, “Once the tsunami of Covid-19 finally recedes, we’re going to be left with the social conditions that enabled the opioid crisis to emerge in the first place, and those are not going to go away.”
The Indian Health Service (IHS) points out that “opioid crisis and COVID-19 pandemic are intersecting with each other” in an insidious way. On one hand, the use of some opioids can lead to respiratory and pulmonary problems, which then makes a person more susceptible to catching Covid-10. Vice versa, having a chronic respiratory disease is likely to increase the risk of fatally overdosing on opioids. Diminished lung capacity as a result of Covid-19 could also lead to similar outcomes among people already on opioids.
On the other hand, isolation and lack of access to recovery support services due to lockdowns and restrictions. Away from peers, mental health services, financial instability, loss of jobs, disrupted routines, stress, housing instabilities.
Research has consistently highlighted a link between poor economic conditions and drug addiction and overdose death rates. This can include increased unemployment, as was seen during the height of the pandemic, or a general, sustained economic downturn — something that has been noted in the U.S. over the last several months.
One of the biggest factors behind the higher risk of fatal overdoses is social isolation, which was the prime characteristic of last year’s Covid-19 lockdowns. In addition to spurring fear and stress, as a result of social isolation, people are more likely to imbibe drugs on their own, and are less likely to have someone around to administer naloxone or to call 911. In desperation and need, they also tend to turn to less reliable suppliers and lower quality products, especially if they are under financial constraints from job losses as well.
Further, on an infrastructure level, lockdown restrictions, isolation protocols, and economic downturns have affected the in-person delivery of addiction recovery services and “drop-in” clinics, limited the number of people that can be treated at facilities, and has even bankrupted some facilities that serve rural or small communities. Providers dependent on private and state funding, or Medicare and Medicaid programs, have also seen their budgets severely slashed by the recession and fall in patient volumes.
Resources have overwhelmingly been directed towards fighting Covid-19. The pandemic has “robbed the oxygen out of the room and made it the sole focus of what’s happening,” according to Dr. Brumage. For instance, a $1 billion research project that hoped to create pain treatments less addictive than opioids was frozen by the federal government.
All of these problems, data, history, and trends tell us, are likely to be disproportionately affecting communities of color — and Native American ones, in particular. The full extent of the effect of this pandemic on the opioid crisis is not yet clear, and researchers will likely take several months — if not years — to deduce the damage really done.