Suicides by drug overdose increased among young people, elderly people, and Black women, despite overall downward trend

A new study of intentional drug overdose deaths, or suicides by an overdose of a medication or drug, found an overall decline in recent years in the United States, but an increase in young people aged 15-24, older people aged 75-84, and non-Hispanic Black women.

The study also found that women were consistently more likely than men to die from intentional drug overdoses, with the highest rates observed in women ages 45 to 64. In addition, factors such as time of year, length of day, and day of the week appeared to be associated with intentional overdose death rates. The study published today in the American Journal of Psychiatry and was led by investigators at the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health.

Nearly 92,000 people died from drug overdoses overall in the U.S. in 2020. This represents the largest increase ever recorded in a calendar year and reflects a nearly five-fold increase in the rate of overdose deaths since 1999.

About 5% to 7% of these overdose deaths are recorded as intentional. Because it can be difficult to determine whether overdose deaths are intentional, the actual numbers are likely even higher. Many people who have a substance use disorder also develop other mental illnesses, such as mood and anxiety disorders, which are independently associated with increased suicide risk. In addition, many people who are diagnosed with other mental illnesses are often diagnosed with a substance use disorder, emphasizing the need to address co-occurring mental health conditions holistically. 

“The distinction between accidental and intentional overdose has important clinical implications, as we must implement strategies for preventing both,” said Nora Volkow, M.D., senior author on the study and director of NIDA. “To do so requires that we screen for suicidality among individuals who use opioids or other drugs, and that we provide treatment and support for those who need it, both for mental illnesses and for substance use disorders.”

Not much is known about who is most at risk of suicide by drug overdose and whether this has changed in recent years. The current study addresses this gap by analyzing data from 2001 to 2019 from the Centers for Disease Control and Prevention’s National Vital Statistics System, which provides data on multiple causes-of-death (including drug overdose death) based on death certificates for U.S. residents.

The NIDA researchers focused on data related to overdose deaths that were classified as intentional. They analyzed these by sex, age, and race/ethnicity, as well as by the month of the year and day of the week when the overdose occurred, to understand the characteristics of these factors. In this study, deaths were reported per 100,000 people to allow for consistent comparisons as the population changed over time.

Despite the steep increase in overdose deaths broadly, the study found that intentional overdose deaths in general have declined in recent years, decreasing among women between 2015-2019 (from 1.7 to 1.5 per 100,000 people), and among men between 2012-2019 (from 1.6 to 1.2 per 100,000 people). Intentional overdose rates generally were higher in women than in men. In each year analyzed, women ages 45 to 64 had the highest rates of intentional overdoses.

However, the investigators also found that age-adjusted intentional drug overdose deaths continued to rise in certain population subgroups. Notably, the rates increased among:

• young men ages 15 to 24 (from 0.6 per 100,000 people in 2015 to 0.8 in 2019)
• young women ages 15 to 24 (from 0.6 per 100,000 people in 2014 to 1.0 in 2019)
• older men ages 75 to 84 (from 0.7 per 100,000 people in 2001 to 1.6 in 2019)
• older women ages 75 to 84 (from 0.8 per 100,000 people in 2001 to 1.7 in 2019), and
• non-Hispanic Black women (from 0.4 per 100,000 people in 2013 to 0.7 in 2019).

The researchers also investigated when overdose deaths were most likely to occur in terms of both days of the week and months of the year. They found that intentional overdose rates were highest on Mondays and lowest on weekends (Friday to Sunday). The researchers pointed out that social factors, such as increased social interactions over the weekend or a reluctance to begin the work week, may contribute to the variability.

Intentional overdose rates also varied by month, with lowest rates noted in December and highest rates in late spring and summer. These findings align with previous observations of seasonal variations in suicide risk. The authors posited some theories that may help explain this pattern, noting that both social and biological factors may play a role in these fluctuations. For instance, low rates in December may be related to a more positive and hopeful mood during the holiday season. Furthermore, they noted that the increase in intentional overdose risk with longer daylight hours in May through August may be related to seasonal changes in the availability of molecules called mu opioid receptors in the brain. These opioid receptors influence mood and behaviors and are targets of opioid drugs, the most frequent substances identified in intentional overdose deaths.

“This research underscores the importance of external support structures and environmental factors in determining a person’s suicide risk,” said Emily Einstein, Ph.D., chief of NIDA’s Science Policy Branch and an author on the study. “The risk of intentional overdoses, and suicide risk in general, is not static. This is crucial for clinicians to keep in mind, as they may need to assess patients’ suicide risk frequently rather than at one point in time. It is also important for friends and family members of people who may be at an increased risk of suicide, and for those people themselves, so that they can be aware of the greatest periods of risk and seek help when needed.”

Rare gene mutation in some Black Americans may allow earlier screening of heart failure

Researchers have linked a rare genetic mutation found mostly in Black Americans and other people of African descent to an earlier onset of heart failure and a higher risk of hospitalization. The findings suggest that earlier screening for the mutation could lead to faster treatment and improved outcomes for heart failure in this vulnerable group, the researchers said. The results of the study, which was largely supported by the National Heart, Lung, and Blood Institute (NHLBI), part of the National Institutes of Health, appear in the Journal of the American College of Cardiology: Heart Failure.

“This is the most comprehensive evaluation of the association between this mutation and measures of cardiac structure, heart function, and heart failure risk in an exclusively Black population,” said lead study author Ambarish Pandey, M.D., assistant professor of internal medicine in the Division of Cardiology at University of Texas Southwestern Medical Center in Dallas. “The results also highlight the importance of early genetic screening in patients at higher risk for carrying the mutation.”

Heart failure is a chronic, debilitating condition that develops when the heart can’t pump enough blood to meet the body’s needs. Despite the name, it does not mean that the heart has stopped beating. Common symptoms include shortness of breath during daily activities or trouble breathing when lying down. The condition affects about 6.5 million people in the United States alone. Black Americans are at higher risk for the condition than any other racial/ethnic group in the U.S., and they experience worse outcomes.

The genetic variant studied in the current research had long ago been linked to a higher risk of heart failure in people of African ancestry. Known as TTR V142I, the gene can cause a condition called transthyretin amyloid cardiomyopathy, which is potentially fatal because protein builds up inside the heart. However, little was known about the impact of the mutation on important clinical-related factors such as heart structure, heart function, hospitalization rates, and blood biomarkers. 

To learn more, the researchers studied TTR V142I in a group of middle-aged participants from the 20-year-long Jackson Heart Study, the largest and longest investigation of cardiovascular disease in Black Americans. Of the 2,960 participants selected from the study, about 119 (4%) had the genetic mutation, but none had heart failure at the start. The researchers followed the participants for about 12 years between 2005 and 2016.

During the study period, the researchers observed 258 heart failure events. They found that patients who carried the genetic mutation were at significantly higher risk of developing heart failure, compared to those without the mutation. These patients also developed heart failure nearly four years earlier and had a higher number of heart failure hospitalizations. Researchers said they found no significant difference in death rates between the two groups during this study period.

During follow-up studies, however, they observed significant increases in blood levels of troponin, a protein complex that is an important marker of heart damage, among carriers of the genetic mutation. They did not see any significant associations between the genetic mutation and changes in heart structure and function as evaluated by echocardiographic and cardiac MRI assessments.

“What that means is that the gene is causing heart damage slowly over time,” said Amanda C. Coniglio, M.D., the lead author of the study and a physician with Duke University School of Medicine in Durham, North Carolina. “The changes are subtle but significant.”

The researchers noted that more studies will be needed to continue assessing participants’ heart structure and function and to see, long-term, if increased hospitalization risk translates into higher risk of death.

“Identification of genetic susceptibility to amyloid cardiomyopathy is an important advance related to heart failure, especially given its disproportionate effect on older and multiethnic populations,” said Patrice Desvigne-Nickens, M.D., a medical officer in the Heart Failure and Arrhythmia Branch in NHLBI’s Division of Cardiovascular Sciences.

Adolfo Correa, M.D., Ph.D., study co-author and former director of the Jackson Heart Study, agreed. “About half of Black American men and women living in the United States today have some form of cardiovascular disease, but the root causes are poorly understood,” he said. “This study brings us a step closer to better understanding this particular form of gene-related heart failure, as well as the life-saving importance of early screening.”  
  

Disparities in opioid overdose deaths continue to worsen for Black people, study suggests

Non-Hispanic Black individuals in four U.S. states experienced a 38% increase in the rate of opioid overdose deaths from 2018 to 2019, while the rates for other race and ethnicity groups held steady or decreased, according to a new study by the National Institutes of Health published in the American Journal of Public Health.

These alarming data are in line with other research documenting a widening of disparities in overdose deaths in Black communities in recent years, largely driven by heroin and illicit fentanyl. The research emphasizes the need for equitable, data-driven, community-based interventions that address these disparities.

The research was conducted as part of the HEALing Communities Study, which aims to significantly reduce opioid-related overdose deaths by helping communities implement evidence-based practices to treat opioid use disorder and reduce other harms associated with opioid use in New York, Massachusetts, Kentucky, and Ohio. It is the largest addiction implementation study ever conducted and is administered in partnership by NIH’s National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration through the Helping to End Addiction Long-term Initiative, or NIH HEAL Initiative.

“We must explicitly examine and address how structural racism affects health and leads to drug use and overdose deaths,” said NIDA Director Nora D. Volkow, M.D. “Systemic racism fuels the opioid crisis, just as it contributes mightily to other areas of health disparities and inequity, especially for Black people. We must ensure that evidence-based interventions, tailored to communities, are able to cut through the economic and social factors that drive disparities in substance use and addiction, to reach all people in need of services.”

For this study, data were collected from death certificates for 2018 and 2019 across 67 communities with a total population of more than 8.3 million people in the four states participating in the HEALing Communities Study. The researchers calculated rates and trends of opioid overdose deaths overall and for each state, and then further analyzed trends by race and ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, other). Overall, the investigators observed no change in the opioid overdose death rate in these states from 2018 (38.3 deaths per 100,000 people) to 2019 (39.5 deaths per 100,000 people). 

However, the researchers observed a 38% overall increase in the opioid overdose death rate for non-Hispanic Black individuals from 2018 to 2019, across these four states. There were no changes overall among the other racial and ethnic groups. Trends varied at the state level and increases among non-Hispanic Black individuals were highest in Kentucky (a 46% increase) and Ohio (a 45% increase). The investigators did not observe a significant increase in Massachusetts among non-Hispanic Black individuals. While opioid overdose death rates were unchanged for non-Hispanic Black individuals in New York, there was an 18% decline among non-Hispanic white individuals, suggesting that non-Hispanic Black individuals have not benefitted equally from prevention and treatment efforts.

The study authors note that these data add to the evidence of increasing disparities in opioid overdose deaths by race and ethnicity, and highlight the importance of access to timely, local data to inform effective community-tailored strategies to reduce these deaths. Numerous evidence-based prevention and treatment interventions exist for addressing the opioid overdose crisis, overdose education and naloxone distribution, medications for opioid use disorder, behavioral therapies, and recovery support services. Unfortunately, these interventions have largely failed to gain widespread implementation in community settings including addiction treatment, general medical care, social support services, schools, and the justice system.

To address this challenge, the HEALing Communities Study is working with local, state, and federal partners to gain access to data on opioid-related overdose fatalities, treatment, and other related health concerns in a timelier fashion and include important demographic information including race and ethnicity. Early access to these data was instrumental in informing HEALing Communities Study intervention planning, including discussions ensuring evidence-based practices are equitably available to all racial and ethnic groups. For example, these data informed partnerships with Black community organizations to improve access to overdose education and naloxone distribution.

While the data presented here were critical in shaping public health response, the timeliness of data about drug use, addiction, and overdose is an ongoing challenge. National and state data are typically collected annually, access to the data is limited, and data may not be available for months. Health data related to race and ethnicity may be limited or completely unavailable, and mortality data are particularly lagged due to the time required for toxicology testing.

“The more local and timely data communities have access to, the more tailored their approach can be for interventions,” said lead author Marc Larochelle, M.D., M.P.H., a general internal medicine physician at Boston Medical Center and assistant professor of medicine at Boston University School of Medicine. “We know there are disparities in implementation of effective strategies for reducing opioid overdose deaths, but early access to better data like these allows communities to address equity with improved intentionality.”

African Americans who smoke seem at higher risk of coronary heart disease

African Americans who smoke appear to have more than twice this risk of  developing coronary heart disease compared to those who do not smoke, a new study has found. The findings — the first up-close look at the relationship between smoking and coronary heart disease in this population—also examined the risk for plaque buildup in the arteries of African Americans who smoke. Excessive plaque in the arteries is a known predictor of heart attacks and heart failure.    

 The study, published today in the Journalof the American Heart Association, draws on data from nearly 4,500 participants in the Jackson Heart Study, the largest cohort study investigating cardiovascular disease exclusively in African Americans. That study, as well as the new research, is supported by the National Heart, Lung, and Blood Institute (NHLBI), and the National Institute of Minority Health and Health Disparities (NIMHD), both part of the National Institutes of Health.    

Coronary heart disease, the leading cause of death in the world, is the most common type of heart disease. In the United States, it affects more than 20 million adults(link is external) and causes one in seven deaths, according to the Centers for Disease Control and Prevention. It can develop when plaques build up in the blood vessels that supply the heart. These clogged, or calcified, arteries can limit or block blood flow and increase the risk for heart attack.    

Compared to whites, African Americans are more likely to die from coronary heart disease. Cigarette smoking causes inflammation and atherosclerosis, and coronary heart disease. Despite a marked decline in smoking among African American adults in recent years, almost 15% reported current cigarette smoking in 2019. Yet the link between cigarette smoking and coronary heart disease has been understudied in this population.    

African Americans have disproportionally higher rates of hypertension, diabetes, and obesity—known risk factors that partly explain the greater death toll from coronary heart disease in this community, according to the researchers.    

“But smoking is also a well-documented risk factor, which, combined with the others, suggest that African Americans smokers represent a particularly vulnerable population for this disease,” said lead study author Adebamike Oshunbade, M.D., M.P.H., a postdoctoral research fellow at the University of Mississippi Medical Center in Jackson. “However, our study is the first to focus on the relationship between cigarette smoking and coronary heart disease exclusively among a large cohort of African Americans.”      

Given the scant inclusion of African Americans in prior studies, researchers had limited ability to single out the specific effects of smoking, distinct from other risk factors, in this population. But with the Jackson Heart Study cohort of 5,306 participants, Oshunbade and colleagues were able to assess the relationship between smoking, coronary heart disease, and coronary artery calcification in African American adults.   

The investigators used coronary artery calcification (CAC) score measurements to assess the degree of calcified plaque buildup in participants’ coronary arteries. CAC score, which is measured by a CT scan, is a key predictor of an individual’s risk for cardiac events like heart attacks.      

For the study, 4,432 participants without a history of coronary heart disease at the time (2000-2004), were classified as current smokers, former smokers, or never smokers. After taking into account other risk factors — including smoking intensity, or the number of cigarettes each consumed daily — researchers followed the participants through 2016, tracking the development of coronary heart disease.     

The researchers found that, compared to those who never smoked, those who currently smoked had a more than two-fold higher risk of coronary heart disease. Similarly, those who smoke had an increased likelihood of having a higher CAC score.   

   “Smoking is a modifiable risk factor for cardiovascular disease and 73% of African American adults who smoke want to quit,” said David Goff, M.D., Ph.D., director of the NHLBI’s Division of Cardiovascular Sciences. “However, compared to whites, African American patients are less likely to receive information about smoking cessation treatments that we know can make a difference. Fully addressing tobacco-related disparities requires addressing conditions where people live, work, and play.” 

As the authors noted, the study was observational, and the findings do not establish casual links. Additionally, they should not be generalized to people of other races or regions.

NIH study links cigarette smoking to higher stroke risk in African Americans

African Americans who smoke are nearly 2.5 times more likely to have a stroke than those who never smoked, while former smokers show a similarly lower risk as never smokers, according to a new study funded by the National Institutes of Health.

The findings from the Jackson Heart Study suggests that even after years of smoking, African Americans — who as a group are twice as likely as whites to have a stroke and die from it — could significantly reduce their risk if they kicked the habit. The study’s findings, funded by the National Heart, Lung, and Blood Institute (NHLBI) and the National Institute for Minority Health and Health Disparities (NIMHD), both part of NIH, will appear online in the Journal of the American Heart Association(link is external).

Numerous studies have shown the link between smoking and stroke, but few have directly assessed the relationship solely in African Americans. This new study did that and also analyzed traditional risk factors for cardiovascular diseases and inflammation.

“This study provides further strong evidence of the link between cigarette smoking and stroke in African Americans,” said David Goff, M.D., Ph.D., director of the Division of Cardiovascular Sciences at NHLBI. “We know that quitting smoking is one way to lower the risk for stroke, which is particularly important for the most vulnerable populations during this pandemic.”

The study included 4,410 black men and women without a history of stroke and who were enrolled in the Jackson Heart Study, the largest study of cardiovascular disease in African Americans. Researchers classified the participants, who were 54 on average, into three groups based on their self-reported smoking history: current smokers, past smokers who smoked at least 400 cigarettes in their lifetimes, and never smokers.

The researchers further classified current smokers based on smoking intensity. One group included participants who smoked up to 19 cigarettes a day; another included those who smoked 20 or more cigarettes a day. Researchers followed participants from their initial evaluations beginning in 2000 through 2015.

At its start, the study included 781 past smokers, 546 current smokers, and 3,083 never smokers. By 2015, 5.2% of past smokers, 6.6% of those were smoking up to 19 cigarettes a day, and 7.2% of those smokers smoking more than 20 cigarettes a day had experienced a stroke, compared to 3.4% of never smokers.

After accounting for multiple risk factors for stroke, such as high blood pressure, diabetes, high “bad” cholesterol levels, and older age, researchers calculated that current smokers carried a risk for stroke that was more than double the risk for never smokers. And, the risk nearly tripled for those smoking 20 or more cigarettes each day. But past smokers showed an almost identical risk as never smokers.

“The bottom line is the more a person smokes, the greater their chance is of having a stroke,” said Adebamike A. Oshunbade, M.D., M.P.H., the lead study author and postdoctoral research fellow at the University of Mississippi Medical Center. “It’s important to communicate this risk to vulnerable populations, especially with the growing popularity of new tobacco products.”

Michael E. Hall, M.D., associate professor of medicine at the University of Mississippi Medical Center, Jackson, and corresponding study author, agreed. He noted that while smoking has been shown in major studies to raise the risk of stroke 1.5 times for the general population, “these adverse health effects seem to be magnified in African Americans.”

In their analysis, the researchers also looked more closely at the already-established link between inflammation and atherosclerosis and smoking. They measured for C-reactive protein (CRP), a marker of inflammation, and carotid intima-media thickness, or CIMT, to assess the buildup of fatty plaques in the carotid arteries that supply blood to the brain.

The researchers found that African American smokers who smoked 20 or more cigarettes a day had higher CIMT compared to never smokers. Researchers said this suggests that the buildup of plaque in the major blood vessels of the brains of African American smokers could play a role in the development of stroke.

During HIV infection, antibody can block B cells from fighting pathogens

NIH scientists suspect process aims to curb immune-system hyperactivity.

Colorized scanning electron micrograph of a B cell from a human donor.NIAID

For the first time, scientists have shown that in certain people living with HIV, a type of antibody called immunoglobulin G3 (IgG3) stops the immune system’s B cells(link is external) from doing their normal job of fighting pathogens. This phenomenon appears to be one way the body tries to reduce the potentially damaging effects of immune-system hyperactivity caused by the presence of HIV, according to the investigators, but in so doing, it also impairs normal immune function.

The research was led by scientists in the Laboratory of Immunoregulation and the Laboratory of Immunogenetics at the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health.

The investigators made their discovery by analyzing blood samples from 83 HIV-uninfected, anonymous donors and 108 people who were living with HIV at various stages of infection. The people living with HIV came from a variety of racial and ethnic backgrounds. Some of these people were being treated for their infection, while others had not yet begun therapy.

The scientists observed that IgG3 appeared on the surface of B cells only under certain conditions. It appeared in people living with HIV, but not in HIV-uninfected people. Also, IgG3 predominantly appeared on B cells of people of African American or black African decent during the chronic phase of untreated HIV infection when the virus was not adequately controlled.

A site on B cells called the B-cell receptor normally binds to foreign entities such as pathogens. This binding stimulates the B cell to produce many copies of the antibody form of the receptor, which can trap a pathogen and mark it for destruction. The scientists found that IgG3 short-circuits this process in certain people living with HIV by docking on the B-cell receptor, blocking it from adequately responding to the pathogen or other intended target. The researchers also demonstrated how other components of the immune system contribute to IgG3 interference with normal B-cell function during HIV infection. Finally, they showed that IgG3 stops binding to B-cell receptors when a chronically infected person starts treatment that controls the virus, illustrating that the IgG3 activity is directly linked to the presence of HIV during chronic infection.