This reflection details my experience facilitating an overdose awareness event and the importance of adapting health equity work to community needs.
Thomas Agostini, MD
Fellow, Medical University of South Carolina, 2022
Agostini T (1)
(1) UW Medicine / Pediatrics Health Equity Track
Opioid use disorder has been an increasing crisis over the past decade, with opioid overdose deaths (OODs) rapidly increasing from 2015-2021. (1) Synthetic opioids, like fentanyl, have largely contributed to the increased incidence of opioid overdose deaths as more drug supplies are getting laced with synthetics. Naloxone, an opioid antagonist, is an overdose reversal drug that has become increasingly more available throughout the United States. Over the past 5 years, many states have made efforts to try and reduce barriers to access to this life-saving medication. Even with this ease in access, there are noticeable inequities for groups facing systems of oppression, including BIPOC and Latine communities, to have inequitable access to naloxone and overdose prevention training. (2) Queer communities also have higher rates of substance use disorders and experiencing homelessness, which could place them at increased risk of overdose deaths. (3) These inequities, while not exclusive to overdose fatalities, are especially concerning due to the high mortality. Healthcare professionals have a duty, as advocates for their patients and their loved ones, to help groups who have been minoritized. Targeted interventions through community partnerships may be a way to address inequities in OODs.
Health equity work has been important to me as I’ve continued my medical education, and the ability to continue this work in residency was appealing to me through a dedicated subspecialty track. I started residency in Seattle this past year, and I quickly realized that the healthcare landscape was drastically different than my former training in South Carolina. Politics, population density, and geographic differences make the two locations polar opposites. With my time in Aequitas as a fellow, I’ve learned to recognize that a pillar of health equity work is adapting to community needs, not imposing my personal interests. Transitioning to the Pacific Northwest, I decided to immerse myself in more local efforts dedicated to harm reduction work.
Seattle, and more broadly, the state of Washington, continues to be disproportionately impacted by OODs. While national OODs have been decreasing, Washington state overdose deaths in the past few years have been increasing by 27%. (4) King County and the larger public health initiatives continue to work on addressing this, with a particular interest in addressing inequity faced by communities facing systemic oppression. Seattle, in addition, is infamous for its history of redlining and current practices of gentrification, continuing this archaic practice of pushing communities of color out of their neighborhoods. (5) While it may be unclear what is the main driver contributing to the increase, it is likely a multifactorial issue related to housing inequality, inadequate substance use services, and lack of mental health resources.
Upon starting residency, I was able to connect with faculty and staff in my program that were hoping to provide more community-based partnerships to help address inequities in harm reduction education. Physicians, nurses, and public health experts helped me and other residents put together educational materials to use for community education sessions. The faculty members we were mentored by had existing relationships with established community organizers dedicated to promoting health for communities of color. We were very excited to present our curated materials and had pre-existing expectations with how the event would play out.
At our first naloxone training, we had about ten people, which was modest but a decent turnout for an inaugural event. We began with standard presentation formalities, introducing ourselves, reviewing objectives, and asking participants about their baseline understanding of opioid overdose. It became clear that the participants had a good overall understanding of the topic, but many of them had a high level of fear based on a few misconceptions. Many of these fallacies were ones commonly sensationalized by the media: fentanyl being put in candy, naloxone being harmful and also getting people high, and the legalization of marijuana being the precipitating factor for the exponential rise of OODs. While this misinformation is certainly not isolated to communities of color, it is especially important to address them given the inequitable access minoritized individuals face in naloxone and overdose prevention.( 2)
It became clear that community members had pre-existing concerns that were not addressed in the slides, and we quickly abandoned our slides and switched to a Q&A style session. Our team then split up with participants into smaller groups to practice naloxone administration and review the material covered during the first half of the session. In the small group portion, community participants continued to ask more questions, often citing lived experiences as bystanders to overdoses. Participants received individual naloxone kits, more information on local resources, and further information about overdose prevention.
What was designed as a top-down educational session, in which facilitators led a largely didactic experience, ended up being a bidirectional learning opportunity. Community members were able to have their direct concerns addressed, and facilitators were able to better understand community needs. Misinformation around marijuana as a “gateway drug”, naloxone causing potential harm to an unconscious person, transdermal absorption of fentanyl, and personal safety in responding to a suspected overdose were all concerns raised by community participants. Upon reflection, the most important thing was addressing individual concerns and not basing community work on preconceived notions of training needs. With existing inequities, conventional methods of community training need to be altered to help meet the needs and desires of BIPOC communities, shifting away from structured didactics and striving towards bidirectional communication between community participants and facilitators. This model, finding similarities and learning from the differences in our unique lived experiences. Addressing the concerns of minoritized communities may be a more beneficial way to help address inequities.
Community events like this often have pedantic undertones - experts not only assume that community members are uneducated on topics, but they also assume that they know exactly what community members want to learn. I am certainly guilty of this, which is why I believe experiential reflection on health equity work is quintessential. There is no “one size fits all" solution to health education efforts for minoritized communities; different groups will have unique concerns and needs. Location, specific inequities from different systems of oppression, and generational trauma can all impact the information desired by communities. With the privilege we hold as healthcare workers, providers have a role to leverage our resources to create accessible opportunities for oppressed communities to share knowledge. This, in turn, creates an opportunity for former participants of these sessions to educate their peers.
Quantitative metrics of these partnerships may help paint a partial picture of event efficacy, but the real opportunities for growth lie in the lived experiences of community members. Just like the starfish fable, we may not be able to change systemic oppression on a larger scale - we can help amplify the work of amazing grassroot efforts who have local initiatives to keep their communities safe.
References:
1. Azadfard M, Huecker MR, Leaming JM. Opioid Addiction. In: StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2023, StatPearls Publishing LLC.; 2023.
2. Khan MR, Hoff L, Elliott L, et al. Racial/ethnic disparities in opioid overdose prevention: comparison of the naloxone care cascade in White, Latinx, and Black people who use opioids in New York City. Harm Reduct J. 2023;20(1):24.
3. Felner JK, Wisdom JP, Williams T, et al. Stress, Coping, and Context: Examining Substance Use Among LGBTQ Young Adults With Probable Substance Use Disorders. Psychiatr Serv. 2020;71(2):112-120.
4. U.S. Overdose Deaths Decrease in 2023, First Time Since 2018 [press release]. Online: CDC, May 15, 2024 2024.
5. Seattle Co. Redlining in Seattle. Accessed 2024. https://www.seattle.gov/cityarchives/
exhibits-and-education/online-exhibits/redlining-in-seattle
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