The Epidemiology of Substance Use Disorders in American Indians and - PowerPoint PPT Presentation

The Epidemiology of Substance Use Disorders in American Indians and Alaska Natives Heidi Lovejoy, MSc Substance Use Epidemiologist Northwest Portland Area Indian Health Board (NPAIHB) Yellowhawk Tribal Health Center March 5 th 2019

National Drug Overdose Deaths: Trend Since 1999 25 21.7 .7 20 Deaths Per 100,000 13.1 .1 15 10.1 .1 10 6.1 .1 5 0 Year Age Adjusted Rates per CDC Wonder Data Northwest Portland Area Indian Health Board

National Drug Overdose Deaths: Trend Since 1999 25 21.7 .7 3.6x 20 Deaths Per 100,000 Increase 13.1 .1 15 10.1 .1 10 6.1 .1 National Public Health 5 Emergency Declared 0 in 2017 Year Age Adjusted Rates per CDC Wonder Data Northwest Portland Area Indian Health Board

National Drug Overdose Deaths: By Race 30 27.5 .5 White (Non-Hispanic) 25 21.7 .7 National Average Deaths Per 100,000 20 16.2 .2 American Indian/ 15 Alaska Native 10 5 0 Year Age Adjusted Rates per CDC Wonder Data Northwest Portland Area Indian Health Board

How Does the Northwest Compare? Northwest Portland Area Indian Health Board

Washington State Drug Overdose Deaths: Trend Since 1999 25 21.7 .7 National Average 20 15.4 .4 Deaths Per 100,000 Washington State 15 10 5 0 Year National Age Adjusted Rates per CDC Wonder Data, Washington Age Adjusted Rates per Washington State Death Certificates Northwest Portland Area Indian Health Board

Washington State Drug Overdose Deaths: By Race 50 43.1 .1 American Indian/ Alaska Native 40 Deaths Per 100,000 30 White (Non-Hispanic) 20 15.3 .3 Washington State 15.4 .4 10 0 Age Adjusted Rates per Washington State Death Certificates Year Northwest Portland Area Indian Health Board

Washington State Drug Overdose Deaths: WA AI/AN vs National 50 43.1 .1 Washington State American Indian/ 2x Alaska Native 40 national rate Deaths Per 100,000 30 21.7 .7 National Average 20 Considered a Public Health Emergency 10 0 Year Age Adjusted Rates per Washington State Death Certificates, National per CDC WONDER Northwest Portland Area Indian Health Board

What Drugs are Involved? Northwest Portland Area Indian Health Board

Washington State Drug Overdose Deaths: What Drugs are Involved? 50 44.6 .6 AI/AN, All OD 70% Deaths Per 100,000 40 Opioids 31.5 .5 AI/AN, Opioid OD 30 20 15.3 .3 White, All OD 10 White, Opioid OD 10.2 .2 0 Year Age Adjusted Rates per Washington State Death Certificates, 3-Year Rolling Averages Northwest Portland Area Indian Health Board

Washington State Opioid Overdose Deaths: Which Opioids? 20 American Indian/Alaskan Native 14.4 .4 Deaths per 100,000 15 Multiple Opioids Morphine 8.7 .7 Codeine 10 Hydrocodone Prescription Opioid Oxycodone Methadone Heroin Etc 7.6 .6 5 Methadone 1.8 .8 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Year Age Adjusted Rates per Washington State Death Certificates, 3-Year Rolling Averages Northwest Portland Area Indian Health Board

Washington State Opioid Overdose Deaths: Which Opioids? AI/AN vs White 20 American Indian/Alaska Native White (Non-Hispanic) Deaths per 100,000 Multiple 15 10 Prescription Heroin Prescription 5 Multiple Methadone Heroin Methadone 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Year Age Adjusted Rates per Washington State Death Certificates, 3-Year Rolling Averages Northwest Portland Area Indian Health Board

Washington State Overdose Deaths: Other Drugs? American Indian/Alaskan Native American Indian/Alaskan Native 20 20 No Opioid Involved in Death Methamphetamine & Deaths per 100,000 Psychostimulants 15 15 15.5 .5 Remove 10 10 Methamphetamine & Opioids 6.6 .6 Psychostimulants 3.4 .4 5 5 Cocaine Cocaine 0.7 .7 0 0 2001 2003 2005 2007 2009 2011 2013 2015 2001 2003 2005 2007 2009 2011 2013 2015 Year Age Adjusted Rates per Washington State Death Certificates, 3-Year Rolling Averages Northwest Portland Area Indian Health Board

Washington State Opioid Overdose Deaths: By Sex and Race 70% 58.8% 55.4% 60% 44.6% 50% 41.2% Percent 40% 30% 20% 10% 0% AI/AN Female AI/AN Male White Female White Male Percent of Deaths per Washington State Death Certificates, 1999-2016 Northwest Portland Area Indian Health Board

Washington State Opioid Overdose Deaths: By Sex and Race Over Time 30 25.0 .0 25 AI/AN Male Rate (per 100,000) 19.6 .6 20 AI/AN Female 15 9.2 .2 10 White Male White Female 5 6.0 .0 0 Year Age Adjusted Rates per Washington State Death Certificates, 3-Year Rolling Averages 1999-2016 Northwest Portland Area Indian Health Board

Washington State Opioid Overdose Deaths: By Age and Sex American Indian/Alaska Native 90 Female 77.8 80 Male 71.0 70 Rate (per 100,000) 61.5 60 52.9 48.8 50 44.8 40 35.5 27.3 30 24.9 19.4 20 10 4.9 0.7 0 0-19 20-29 30-39 40-49 50-59 60+ Age Group Age Adjusted Rates per Washington State Death Certificates, 1999-2016 Northwest Portland Area Indian Health Board

Washington State Opioid Overdose Deaths: By Race, Age, and Sex AI/AN Female 90 77.8 80 AI/AN Male 71.0 70 61.5 60 Deaths per 100,000 White Female 52.9 48.8 50 44.8 White Male 40 35.5 34.4 27.8 30 27.3 24.9 24.9 24.2 22.9 19.7 19.4 20 15.4 8.4 8.0 10 7.5 4.9 1.6 0.7 0.9 0 0-19 20-29 30-39 40-49 50-59 60+ Age Group Age Adjusted Rates per Washington State Death Certificates, 1999-2016 Northwest Portland Area Indian Health Board

Opioid and Overdose Epidemiology Data Challenges • Racial misclassification • Many AI/AN are not classified as AI/AN in state data systems = underrepresentation of burden on AI/AN • Limited access to behavioral health/treatment data • Hard to know prevalence of SUD or treatment for SUD • Difficulty obtaining tribe-level data • Can only provide regional data • Inconsistency in overdose cause of death reporting • What drug(s) actually involved? Northwest Portland Area Indian Health Board

Racial Misclassification: What we do about it  We fix race in the data Process: NTR 1. Obtain state data, like death certificates 2. Link data with the National Tribal Registry 3. Check if AI/AN is indicated one database but not National Tribal Registry Death certificates the other AI/AN AI/AN 4. Correct racial classification ? AI/AN AI/AN White White AI/AN 5. Do our own statistics with the corrected data Northwest Portland Area Indian Health Board

Washington State Drug Overdose Deaths: Race Corrected vs Race Un-Corrected 50 AI/AN Race Corrected Up to 20% underrepresentation 40 Deaths per 100,000 in AI/AN overdose death rate 30 AI/AN Race Un-Corrected 20 White (non-Hispanic) Race Corrected and Un-Corrected 10 No difference in rates 0 Northwest Portland Area Indian Health Board

Washington State Drug Overdose Deaths: by Reporting Agency 2016 AI/AN Drug Overdose Death Rate in Washington 50 43.1 35.6 40 Deaths per 100,000 31.9 Race- 30 Corrected Not Race- AI/AN Corrected 20 -ONLY- 10 0 CDC NPAIHB WA DOH Reporting Agency Northwest Portland Area Indian Health Board

Washington State Drug Overdose Deaths: by Reporting Agency 2016 AI/AN Drug Overdose Death Rate in Washington 50 43.1 40 35.6 State data reports 20% lower Deaths per 100,000 31.9 Race- 30 Corrected Not Race- AI/AN Corrected 20 -ONLY- 10 0 CDC WA DOH NPAIHB Reporting Agency Northwest Portland Area Indian Health Board

Washington State Drug Overdose Deaths: by Reporting Agency 2016 AI/AN Drug Overdose Death Rate in Washington 50 43.1 40 35.6 Deaths per 100,000 National data reports 30% lower 31.9 Race- 30 Corrected Not Race- AI/AN Corrected 20 -ONLY- 10 0 CDC NPAIHB WA DOH Reporting Agency Northwest Portland Area Indian Health Board

National Drug Overdose Deaths: By Race 30 ? 27.5 .5 White (Non-Hispanic) 25 21.7 .7 National Average Deaths Per 100,000 20 16.2 .2 American Indian/ 15 Alaska Native 10 AI/AN rates may 5 be higher nationally? 0 Year Age Adjusted Rates per CDC Wonder Data Northwest Portland Area Indian Health Board

Take Away Messages • Deaths from drug overdoses are increasing • Most overdose deaths involve opioids • People aged 40-49 have the most overdose deaths • Nationally, AI/AN have a lower overdose death rate than whites • In Washington, AI/AN have the highest overdose death rate (3x whites) • National and state statistics may significantly underestimate AI/AN statistics Northwest Portland Area Indian Health Board

Thank You! Questions? Heidi Lovejoy, MSc Substance Use Epidemiologist Northwest Portland Area Indian Health Board HLovejoy@NPAIHB.org Northwest Portland Area Indian Health Board

Why use rates? To compare across groups with different sized populations Scenario: Group B: Group A: 100 people 1,000 people 50 people die of a disease in both groups. Same number of deaths. Group B: Group A: 50/100 = 50% died. 50/1,000 = 5% died. Really bad!! Not good. This is why we use rates – to compare across populations Northwest Portland Area Indian Health Board