The Opioid Crisis And The Hispanic/Latino Population: An Urgent Issue

experience, peer recovery coach, peer recoverysupervisor, executive director and staff ofcommunity-based programs, evaluator, researcher,internist, addiction psychiatrist, clinicalpsychologist, physician, social worker, nurse, andadvocate. Key informants were from geographicallydiverse areas and represented various types ofinstitutions, e.g., university, professional behavioralhealth association, hospital, health clinic, andcommunity-based organizations (CBOs).Unique to this brief is the compilation of issues andstrategies conveyed by people living or working inHispanic/Latino communities and addressingopioid misuse and substance use disorder SUD ,and include many who identify as Hispanic/Latino.Their direct statements, indicated by italics andquotation marks, are interspersed throughout thedocument. The information they shared representsa snapshot of what is happening in selectedHispanic/Latino communities struggling withopioid misuse, and is not a full comprehensivepicture of this population across the country.ContextualIssues RelatedTo Opioid MisuseAnd OUD InHispanic/LatinoCommunitiesG LGOOLDNational and state opioid estimates and rates are fromthe Substance Abuse and Mental Health ServicesAdministration (SAMHSA) National Survey on DrugPAGE 2Use and Health SDUH , the National Instituteon Drug Abuse (NIDA) Monitoring the FutureSurvey (MTF),(7, 8) and the Centers for DiseaseControl and Prevention (CDC) National VitalStatistics System(9) and Youth Risk Behavior Survey(YRBS).(10) In the figures and tables below, mostrecently available data are shown.Opioid misuse.(3) According to the SAMHSANSDUH, the opioid misuse (heroin use andprescription opioid misuse) rate among Hispanic/Latinos is similar to the national population rate,about 4 percent. In 2018, 1.7 million Hispanic/Latinos and 10.3 million people nationally, aged 12and older, were estimated to have engaged in opioidmisuse in the past year.Opioid and other substance use and misuse amongHispanic/Latino youth. National data from multiplesources specific to high school aged youth indicatethat Hispanic youth are using drugs at rates that areequivalent or higher compared to their racial/ethnicpeers. In 2017, the CDC YRBS reported that highschool Hispanic youth had the highest prevalence ofselect illicit drug use (16.1 percent) and prescriptionopioid misuse (15.1 percent) compared to the totalhigh school youth population (14.0 percent for both)and other race/ethnicities.(11) Similarly, NIDA’s 2018MTF indicates that in general, Hispanic eighthgraders had the highest levels of substance misuseacross all substances compared to Whites andAfrican Americans.(7, 8) In general, a higherpercentage of Hispanic eighth and tenth grade youthreported opioid (heroin and prescription) misuse inthe past year than Whites and African Americans(Table 1).(7, 8)Opioid-related overdose death rates and deathsinvolving selected drugs by race/ethnicity. Theopioid-related overdose death rate for the nationalpopulation has risen from 2.9 deaths per 100,000people in 1999(12) to 14.9 per 100,000 in 2017(1)—witha large increase in overdose deaths involvingsynthetic opioids other than methadone (syntheticopioids, i.e., fentanyl, fentanyl analogs, andtramadol) from 2013 to 2017.(1) In 2017, amongHispanics the opioid-related overdose death rateTHE OPIOID CRISIS AND THE HISPANIC/LATINO POPULATION: AN URGENT ISSUE

was 6.8 deaths per 100,000 people, and wassignificantly lower compared to non-HispanicWhites, Blacks, and American Indian/Alaska Natives(Table 2). (13)Overdose deaths involving synthetic opioids (otherthan methadone). Data suggest that illicitlymanufactured synthetic opioids are heavilycontributing to current drug overdose deaths in theU.S.(2) The sharp increase in overdose deathsinvolving synthetic opioids in recent years isalarming and data show that the mixing of syntheticopioids with other drugs occur across populations.Synthetic opioids are affecting opioid deathTHE OPIOID CRISIS AND THE HISPANIC/LATINO POPULATION: AN URGENT ISSUEPAGE 3

rates among Hispanics. , ,n, syntheticopioids accounted for nearlypercent of theopioid-related overdose deaths andpercent of thetotal drug overdose deaths for Hispanics, comparedto 41-70 percent, and 25-43 percent of deaths,respectively, for all other race/ethnicities (derivedfrom Table 2).(13)have experienced high rates of heroin dependenceand overdose fatalities since the 1960s, which mayhave set the stage for more recent increases in opioidmisuse and overdose rates among Hispanics in theSouthwest region.(17)Percent increase in overdose death rates by drugamong the Hispanic population. From 2014-2017,among the Hispanic population drug overdose deathrates involving all types of opioids increased, withthe sharpest rise from synthetic opioidsigure . , Death rates involving syntheticopioids increased bypercent, and was thesecond highest for Hispanics compared to all otherrace/ethnicities data not shown . ,Opioid rela ed overdose dea ra ess a e.The picture of opioid-related overdose by statepopulation varies depending on whether death rate,percentage of deaths, or absolute numberof deaths by race/ethnicity are being considered.State opioid-related overdose death data specific toHispanics was available for about half of the states,and of these states the top five states with the highestdeath rate Table and number of deaths Tableare shown. n, Massachusetts had the highestopioid-related overdose death rate for Hispanics. deaths per,. ew Me ico had thehighest percentage of Hispanic opioid-relatedoverdose deaths by state populationpercent ofopioid-related overdose deaths inin ewMe ico were among Hispanics data not shown . Anumber of Hispanic communities in the SouthwestPAGE 4GIn the general population, the increase inprescription opioids for patients with acute andchronic pain(18, 19) contributed significantly to thecurrent crisis and prompted the CDC to issue opioidearlypercent of theprescribing guidelines.U.S. populationand older last misused aTHE OPIOID CRISIS AND THE HISPANIC/LATINO POPULATION: AN URGENT ISSUE

prescription pain reliever for physical pain.(6) For theHispanic/Latino population, opioid misuse stemmingfrom overuse of pain relievers is also a majorpathway to opioid misuse. The key self-reportedreasons for misusing a prescription pain relieveramong Hispanic/Latinos aged 12 or older was torelieve physical pain (53 percent) followed by a needto increase or decrease the effect of some other drug(11 percent).(6) Among Hispanic/Latino youth, aged12 to 17, reasons for misusing a pain reliever were torelieve physical pain (67 percent); to help with one’sfeelings or emotions (12 percent); and to help withone’s sleep (8 percent).(6)Occupational exposures have been associated with theuse of opioid pain medications in the Hispanic/Latino population. Military service increases risk forinjury and ensuing need for pain medications.Hispanic/Latinos have an increasing presence in themilitary and have been over-represented among theenlisted recruits.(21) A higher proportion of MexicanAmericans have blue-collar manual labor jobs thannon-Hispanic Whites, and past research suggests thatMexican Americans with chronic pain may be atgreater risk of experiencing widespread pain thannon-Hispanic Blacks and Whites making them moresusceptible for multiple injuries and higher rates ofdisability.(22-24) A study of emergency departments inthe northeast U.S. found that Hispanic/Latino andBlack children, and nonwhites in general weresignificantly less likely to receive an opioidprescription than Whites for pain, despite reportingsimilar levels of pain severity.(25) In contrast, otherstudies have suggested that opioid prescribing andlevels of pain at presentation in emergencydepartments are similar between non-HispanicWhites and Hispanic/Latinos.(26) Another study usingnationally representative data from 2000 to 2015found that Hispanic/Latino individuals use lessprescription opioids than non-Hispanic Whites andBlacks.(27) However, when Hispanics/Latinos doreceive opioid prescriptions from a medical provider,pharmacies in neighborhoods where they reside, maynot stock these medications. , Efforts to addressthe opioid crisis in these communities, especially inunderserved or low socioeconomic statuscommunities, need to consider how pain intersectswith opioid use and misuse “we need acomprehensive approach to pain management.”O O UL UGLOODIt is now recognized that the social determinants ofhealth are critical contributing factors to majorpublic health issues. Described below are some ofthe key sociocultural factors associated with opioidmisuse within the Hispanic/Latino population. Theyinclude facilitators and barriers to accessingappropriate prevention, treatment, and recoveryservices and supports.a ilis o. amilismo is the term used in Hispanic/atino culture to underscore the importance of thefamily and family roles.amilismo emphasi esthe critical role of internal family dynamics,e tended social networks, and the distribution ofresources through these networks. This conceptis critical to prevention, treatment, and recoveryapproaches for Hispanic/ atino communities. ngeneral, SUD treatment interventions based onfamily system models and involvement of familymembers throughout the treatment continuum,from engagement through continuing care haveshown success.eligio ai a d spiri uali . eligion is valuedin many Hispanic/ atino communities, withpercent of Hispanic/ atinos identifying with aecogni ing the importance of faith andreligion.spirituality in many Hispanic/ atino communities isneeded when considering effective engagement inprevention, treatment, and recovery interventions.igra io issues. n recent decades, civil wars,economic insecurity, poverty, and natural disastershave contributed to the growing Hispanic/ atinopopulation in the U.S. These circumstances alsoinfluence the e perience during migration to, as wellas living in the U.S. Trauma associated with leavingone s native country and acculturating to a newcountry can manifest as a mental health condition.or e ample, research indicates that in general,migrants who are fleeing persecution have highprevalence of mental health conditions such asSimilarly,an iety, depression, and PTSD.research has shown that fears of detention anddeportation of immigrants by law enforcement isTHE OPIOID CRISIS AND THE HISPANIC/LATINO POPULATION: AN URGENT ISSUEPAGE 5

associated with mental health issues for the detainee/deportee and their family.(36-38) Immigration, thoughan opportunity and necessity for some individuals,for many Hispanic/Latinos, is a chronic stressor.Discrimination and trauma. Discriminationexperienced by Hispanic/Latinos and people of color,in general, may trigger flashbacks of past trauma.People who experience a mental illness during theirlives may also experience a SUD. According to the2018 NSDUH, 1.34 million Hispanic or Latino adults,age 18 and over, had a co-occurring SUD and mentalillness in the past year.(3) For Hispanic/Latinos,discrimination toward their ethnicity and immigrationstatus, is also linked to SUDs.(39, 40) Data from theNational Epidemiologic Survey on Alcohol andRelated Conditions suggest that people with mental,personality, and SUDs were at an increased risk fornonmedical use of prescription opioids.(41)Heterogeneity of the Hispanic/Latino population.Combining all Hispanic/Latinos into one ethniccategory is problematic because it overlooks theexisting diversity in Hispanic/Latino communities.One Hispanic/Latino treatment provider shared,“Hispanic Latino communities are a real spectrumthird generation versus recently immigrated individuals,those who are beginning to assimilate, and blendedfamilies, but these individuals don’t have accessbecause of language, insurance, and cultural barriers.”These communities include many different cultures,countries of origin, and languages/dialects. For thosewho immigrated to the U.S., length of residence andlevels of acculturation are quite variable. Similarly,many Hispanic/Latino families are of mixed-status—native, naturalized, and undocumented residents—living in one multigenerational household.Differences in health beliefs and terminologyregarding substance use may vary widely among theHispanic/ atino ethnic groups, e.g., Me icanAmericans, Puerto icans, Cuban Americans, etc.drug being used. In some cases, multigenerationalhouseholds are misusing opioids and other substancestogether, both intentionally and unintentionally. In2016, it was estimated that 27 percent of Hispanics/Latinos in the U.S. lived in multigenerationalhouseholds.(42) In some cases in states where “pillmills” are more common, older generations within afamily may be providing prescription opioids toyounger generations without understanding thepotential for opioid misuse. One key informantshared that some “ Hispanic Latino grandparents aregiving pills to their grandkids.” In thesemultigenerational households, mental illness may alsobe co-occurring among multiple family membersand generations. In communities with high povertyand economic disinvestment, intergenerational andpolysubstance use are not uncommon. For many inthese poor and low-income communities, using and/or selling drugs is a means of survival. Opioids arenot the only substances of concern and are likely notbeing misused in isolation.Risks for youth. Hispanic/Latino youth are unawareof the risk for OUD with prescription opioids.Community members and national data haveindicated that Hispanic/ atino youth are usingopioids at high rates, and sometimes higher than theirracial/ethnic counterparts. , , Hispanic/ atinoyouth, like all adolescents, are at risk for negativecoping behaviors such as engaging in risky se ualbehaviors and drug use. Stress related toacculturation and immigration issues may alsomanifest negatively and place Hispanic/ atinoimmigrant youth at risk for an iety, depressivesymptoms, and PTSD. -erge era io al su s a e isuse a dpol su s a e use. or many families in theU.S., substance misuse is passed on from generationto generation and opioids are not the first or onlyPAGE 6THE OPIOID CRISIS AND THE HISPANIC/LATINO POPULATION: AN URGENT ISSUE

One mental health treatment provider shared thatHispanic/Latino students belonging to mixed statusfamilies were being isolated from peers andtreatment providers when families take theirchildren out of school for their behavioral healthissues; There are a tremendous amount of mixedfamilies. hildren are documented, but parents arenot. iggest risk factor of kids with anxiety anddepression is isolation . They are so isolated andhave nowhere to go at or years old.” Among earlyadolescent Hispanic/Latino youth, the pressure andnegative feelings about being the family interpreteror cultural broker has been associated withacculturation stress which is linked to higher risk forengaging in substance use.(46)Language barriers One of the most commonly citedissues regarding prevention, treatment, and recoverystrategies related to the opioid crisis for Hispanic/Latino communities is the need for bilingualproviders and materials in one’s native language.U.S. Census Bureau data from 2013 show that 63percent of the total U.S. population who reportedlimited English proficiency (LEP) were Hispanic/Latino, while Hispanic/Latinos comprised only 12percent of the U.S. English proficient population.(47)A lack of Spanish-, Portuguese-, and Indigenousspeaking providers, and in-language health-relatedmaterials is a major barrier for Hispanic/Latinopeople with LEP seeking health care in general(48, 49)and especially interferes with accessing care for ahighly sensitive and stigmatized condition such asOUD. Research has indicated that mental healthclinics that provide culturally and linguisticallyappropriate mental health services for thePortuguese-speaking population in their communitywere more likely to provide ade uate care to theirpatients than those providing standard care.Access to free interpreters for individuals, for whomEnglish is not their primary language, is re uired byfederal law at health care facilities receiving federalfinancial assistance. However, despite this law, keyinformants noted that many treatment providers donot ade uately provide interpretation and properlyinform clients of their right to no cost interpretationservices. nstead, key informants commonly reportedthat Hispanic/ atino youth often serve as informalinterpreters for their parents while navigating theprimary and behavioral health care system. As onekey informant stated, “ ids are used all of the time toact as interpreters. You see it in the hospital. In thedoctor’s office or hospital, there is a child serving asinterpreter.”Stigma, misperceptions, and negative narrativesabout SUD. Similar to the general population, thereis a stigma associated with SUD including OUD inHispanic/Latino communities. Many families andcommunities in the U.S. stigmatize people who haveOUD and see it as a moral failing and not a treatable,chronic disease. As one key informant noted,“ eople are hiding addiction, especially Latinos. Themessage is not getting to them that addiction is adisease.” Because of the stigma, many people will notseek treatment.In Hispanic/Latino communities, there is a gap inknowledge about treatment options for OUD. A keyinformant shared about medication-assistedtreatment (MAT) and naloxone, “ ost Latinos areunaware that these programs exist.” To engage andinform this community, specific Hispanic/Latinofocused educational and social marketing campaignson opioid prevention, treatment, and recovery areneeded. As one key informant noted, “T in theLatino community I still see families thinking it isdrug substitution till lots of education that needs tobe done till lots of stigma around. on’tunderstand how it works.” In some cases families arethe obstacle. Key informants shared that Hispanic/Latino families often do not understand addiction,have seen their family member relapse repeatedly,and do not believe in the possibility of recovery.n addition to stigma, misperception of need fortreatment by Hispanic/ atinos with SUDis also a barrier to care. Only five percent ofHispanic/ atinos with a SUD reported perceiving aOne key informant describedneed for treatment.the Hispanic/ atino participants from an ongoingsubstance use study in this manner “The importanceof telling them and identifying for them where in theseverity spectrum they are, had a big impact. hengiven scores to control their condition, so we couldrefer them people started reducing their substanceuse ust by being given their severity score.”THE OPIOID CRISIS AND THE HISPANIC/LATINO POPULATION: AN URGENT ISSUEPAGE 7

Fear of seeking treatment and calling the usualfirst responders. As noted previously, fears andstress related to immigration status are pervasive inHispanic/Latino communities. Many documentedand undocumented Hispanic/Latinos will not seektreatment for themselves, family members or friendsfor fear of deportation. “They won’t call lawenforcement, we see with domestic violence victimsbut also true for people with mental illness andsubstance use disorder. They may be going througheverything but they will not call the law enforcement.”Efforts to improve access to treatment or tonaloxone through the use of first responders and lawenforcement is likely not going to be effective forthese communities. Fo

NSDUH, the opioid misuse (heroin use and prescription opioid misuse) rate among Hispanic/ Latinos is similar to the national population rate, about 4 percent. In 2018, 1.7 million Hispanic/ Latinos and 10.3 million people nationally, ged 12 and older, were estimated to have engaged in opioid misuse in the past year. Opioid and other substance .