Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                

Cano 2021

Download as pdf or txt
Download as pdf or txt
You are on page 1of 8

International Journal of Drug Policy 90 (2021) 103079

Contents lists available at ScienceDirect

International Journal of Drug Policy


journal homepage: www.elsevier.com/locate/drugpo

Research paper

Drug overdose mortality among stateside Puerto Ricans: Evidence of a


health disparity
Manuel Cano a,∗, Camila Gelpí-Acosta b
a
University of Texas at San Antonio, 501 W. César E. Chávez Blvd., San Antonio, TX, 78207, USA
b
LaGuardia Community College, City University of New York, 31-10 Thomson Avenue, Long Island City, NY, 11101, USA

a r t i c l e i n f o a b s t r a c t

Keywords: Background: This study compared drug overdose mortality rates in Puerto Rican-heritage and Non-Hispanic
Drug overdose mortality (NH) White individuals in the United States (US), examining time trends and recent variation by age, sex, state
Puerto Rico of residence, and drugs involved in overdose.
Disparity
Methods: Death certificate data from the National Center for Health Statistics, as well as American Community
Survey population estimates, were used to calculate age-specific and age-adjusted drug overdose mortality rates
for Puerto Rican-heritage and NH White residents of the 50 United States or District of Columbia (DC). Rates for
2018 were compared between Puerto Rican-heritage and NH White individuals, overall and by sex, age, state, and
specific drug involved in overdose. Joinpoint Regression was used to examine trends in drug overdose mortality
rates from 2009 to 2018.
Results: From 2009 to 2018, the age-adjusted drug overdose mortality rate in stateside Puerto Ricans doubled
among women (from 6.0 to 12.5 per 100,000) and nearly tripled among men (from 15.3 to 45.2 per 100,000). In
2018, the age-adjusted drug overdose mortality rate was significantly higher in Puerto Rican-heritage than NH
White individuals (28.7 vs. 26.2 per 100,000, respectively). The 2018 drug overdose mortality rate was highest
among Puerto Rican-heritage men ages 45–54 (104.1 per 100,000).
Conclusion: Findings emphasize the necessity of policies, programs, and interventions to mitigate risk of fatal
overdose in stateside Puerto Rican communities.

Between 2000 and 2018, more than 750,000 lives were lost to drug Rican-heritage population is observed across all geographic areas and
overdose in the United States (US; Centers for Disease Control & Preven- demographic subgroups. An understanding of the subgroups most at
tion [CDC], 2020a). Although some of the highest drug overdose mor- risk within stateside Puerto Rican communities is necessary to target
tality rates in recent years have been documented among Non-Hispanic interventions to mitigate elevated rates of drug overdose mortality.
(NH) Whites in the US (Jalal et al., 2018; Shiels, Freedman, Thomas & A rich body of research has examined drug use in Puerto Rican com-
Berrington de Gonzalez, 2018), the 2017 drug overdose mortality rate munities, both in Puerto Rico and in selected locations in the continen-
for individuals of Puerto Rican heritage in the US exceeded the rate tal US, often in the context of risk behaviors for HIV (Abadie, Welch-
for NH Whites (Cano, 2020). The burden of drug overdose mortality Lazoritz, Gelpi-Acosta, Reyes & Dombrowski, 2016; Deren, Kang, Colón
in Puerto Rican populations represents a racial/ethnic health disparity, & Robles, 2007, 2012; Gelpí-Acosta, Hagan, Jenness, Wendel & Neai-
especially in light of disproportionate exposure to residential segrega- gus, 2011, 2016, 2019; Hautala, Abadie, Khan & Dombrowski, 2017),
tion, discrimination, poverty, and constrained opportunities (Burgos & with relatively less focus on drug overdose mortality specifically. The
Rivera, 2012). rapidly-evolving conditions of the contemporary drug overdose cri-
This disparity is often obscured in national analyses, as data for sis and the inundation of drug markets with deadly synthetic opi-
Puerto Rican-heritage individuals are included in the overall “Hispanic” oids (Ciccarone, 2019) warrant continued research. The present study,
category, a category with lower drug overdose mortality rates relative therefore, examines national trends and recent patterns in drug over-
to NH Whites or NH Blacks (Shiels et al., 2018). It is unclear whether the dose mortality among Puerto Rican-heritage individuals in the 50 US
disproportionately high drug overdose mortality rate in the US Puerto states/District of Columbia (DC).


Corresponding author.
E-mail address: manuel.cano@utsa.edu (M. Cano).

https://doi.org/10.1016/j.drugpo.2020.103079

0955-3959/© 2020 Elsevier B.V. All rights reserved.


M. Cano and C. Gelpí-Acosta International Journal of Drug Policy 90 (2021) 103079

Background munities, especially for Puerto Ricans who migrated to the 50 states/DC
after initiating drug use in Puerto Rico. Some individuals who use drugs
Recent trends in drug overdose mortality in the US in Puerto Rico move to the 50 states/DC due to recruitment by state-
side religious drug treatment centers (Deren et al., 2014). Researchers
Although drug overdoses have contributed to premature mortality describe a drug injection sub-culture in Puerto Rico involving injection
for more than a century (Tkacik, 2019), drug overdose mortality has locations (“shooting galleries”), individuals whose informal job consists
risen to an unprecedented height, extent, and prominence in the United of injecting others, widespread injection drug use in the prison system,
States throughout the opioid crisis of the past three decades. While and explicit and implicit rules surrounding drug use (Gelpí-Acosta et al.,
underlying social/economic conditions and unaddressed drug addic- 2019). Puerto Rico historically embraced an abstinence-only, religious-
tion remain persistent factors (Dasgupta, Beletsky & Ciccarone, 2018; based approach to treatment (Deren et al., 2014), and Puerto Rican mi-
Kolodny et al., 2015), the US drug overdose crisis continually evolves grants who inject drugs in New York City have reported punitive, shame-
as the drugs most involved in overdose shift. Following increases in the based techniques in Puerto Rican treatment centers (Gelpí-Acosta et al.,
prescription of opioid pain-relievers in the 1990s, rising rates of pre- 2019). According to qualitative research, some Puerto Rican migrants in
scription opioid-involved overdose deaths were documented beginning New York City who inject drugs espouse abstinence-only ideals, are am-
in 1999, followed by increases in heroin-involved overdose deaths be- bivalent about medication-assisted treatment and harm reduction, and
ginning in 2010 (CDC, 2020b). Since 2013, synthetic opioids such as fen- do not carry naloxone even when it is available without cost (Gelpí-
tanyl have been considered the driver of overdose deaths (CDC, 2020b), Acosta et al., 2019). People who inject drugs in Puerto Rico have limited
and rising rates of overdose deaths involving stimulants have also been access to naloxone (Gelpí-Acosta, Rodríguez-Díaz, Aponte-Meléndez &
recently documented (Hoots, Vivolo‐Kantor & Seth, 2020). Abadie, 2020) and as such may not be habituated to incorporating this
medication in their everyday routines, even after moving to a location
Puerto Rican populations where naloxone is more readily available. The lack of overdose surveil-
lance in Puerto Rico and ubiquitous abstinence-based approach to drug
In 2018, an estimated 5.8 million individuals of Puerto Rican her- treatment may also indirectly undermine overdose awareness among in-
itage resided in the 50 states/DC (i.e., “stateside”), with an additional dividuals who initiated drug use in Puerto Rico.
3.2 million individuals living in Puerto Rico (U.S. Census Bureau, n.d.).
Approximately 29% of Puerto Rican-heritage individuals living in the
The present study
50 states/DC were born in Puerto Rico (Noe-Bustamante, Flores & Shah,
2019). Migration from Puerto Rico to the 50 US states/DC has recently
In order to target interventions to address drug overdose mortal-
escalated in the wake of Hurricane Maria, with approximately 133,500
ity among Puerto Rican-heritage individuals, a necessary first step in-
Puerto Ricans migrating in 2018 alone (Glassman, 2019). Even prior to
cludes documenting which geographic areas and subgroups (e.g., by
Hurricane Maria, the economic crisis in Puerto Rico fueled high levels
sex or age) are most severely impacted and what drugs are most com-
of migration, including more than 597,000 migrants between 2006 and
monly implicated. The present study, therefore, first aims to deter-
2017 (Mora, Dávila & Rodríguez, 2018).
mine whether the disproportionately high drug overdose mortality rates
Compared to NH Whites, Puerto Rican-heritage individuals living in
observed in Puerto Rican-heritage individuals overall, relative to NH
the 50 states/DC report a lower median age (31 vs. 44 years), lower ed-
Whites (Cano, 2020), are observed in men, women, various age groups,
ucational attainment (20% vs. 7% with less than a high school diploma,
and various states, and for overdoses involving different types of drugs.
among ages 25 and older), and a higher unemployment rate (7% vs. 4%,
Second, the study examines trends over the past ten years (2009–2018)
among ages 16 and older; US Census Bureau, n.d.). Furthermore, com-
to characterize changes over time. The study focuses on individuals of
pared to the overall US population, they report a lower median house-
Puerto Rican-heritage, due to the paucity of nationwide data on drug
hold income ($46,809 vs. $61,937), higher rates of poverty (22% vs.
overdose mortality in this population; however, rates are compared
13%), and lower rates of home ownership (39% vs. 64%; US Census Bu-
against NH White individuals (the largest racial/ethnic group in the US
reau, n.d.). The enduring effect of the colonial history of Puerto Rico is
and the group with some of the highest recent drug overdose mortality
not limited to constrained opportunities; mental health effects of inter-
rates; Shiels et al., 2018) in order to provide a frame of reference and
nalized oppression have also been documented (Capielo Rosario, Schae-
illuminate racial/ethnic health disparities.
fer, Ballesteros, Rentería & David, 2019), and an estimated 40–86% of
stateside Puerto Ricans report experiencing discrimination (Arellano-
Morales et al., 2015; Pérez, Fortuna & Alegria, 2008). Methods

Drug use in Puerto Rican communities Data source

Prior research has documented a higher prevalence of substance use The study utilized data from the restricted-access 2009–2018 Multi-
disorders among individuals of Puerto Rican heritage, compared to other ple Cause of Death files from the CDC’s National Center for Health Statis-
US Hispanic heritage groups (Alegría et al., 2007, 2008). Puerto Ricans tics (NCHS); data access was approved after submitting an application
also represent the Hispanic group with the highest HIV incidence and and data user agreement to NCHS. The Multiple Cause of Death files are
mortality rates, intertwined with injection drug use (Colon et al., 2006; comprised of death certificate data from all recorded US deaths each
Deren et al., 2014). Since the 1960s, researchers have documented resi- year. Demographic information on the death certificate is completed by
dential segregation, constrained opportunities, and depressed economic a funeral director, generally informed by a next of kin (Arias, Heron and
conditions, following the loss of the manufacturing jobs for which many Hakes, 2016). Information on the causes and circumstances of the death
Puerto Ricans had migrated, motivating the participation of some Puerto is provided by a medical certifier such as a coroner, physician, or med-
Rican-heritage individuals in the drug trade in cities such as New York ical examiner (Brooks & Reed, 2015), and each death certificate speci-
City, Chicago, and Hartford (Rosenblum et al., 2014). In modern-day fies one underlying cause of death and up to 20 contributing “multiple
“hypersegregated” Puerto Rican communities in Philadelphia, poverty causes of death” (CDC, 2020a).
and a lack of employment create conditions conducive for a thriving The present study focused on deaths of US residents that occurred
narcotics business (Friedman et al., 2019; Rosenblum et al., 2014). in the 50 states or DC, for which the death certificate indicated drug
In addition to conditions in the 50 states/DC, conditions in Puerto overdose as the underlying cause of death (International Classification
Rico are also relevant for drug use risks in stateside Puerto Rican com- of Disease [ICD] codes X40–44, X60–64, X85, or Y10–14). The study

2
M. Cano and C. Gelpí-Acosta International Journal of Drug Policy 90 (2021) 103079

focused on drug overdose decedents identified as of Puerto Rican her- yearly American Community Survey (ACS). IPUMS ACS one-year popu-
itage; NH White drug overdose decedents were also included for compar- lation estimates were used for both Puerto Rican heritage and NH White
ison. Puerto Rican heritage and Non-Hispanic White race were mutually- race for consistency and comparison, even though bridged-race postcen-
exclusive categories determined based on information on the death cer- sal estimates are available for NH Whites.
tificate under “decedent’s race” and “Hispanic origin,” and an individual All mortality rates were expressed per 100,000, and all rates (ex-
could be identified as of Puerto Rican heritage regardless of whether cept age-specific rates) were age-adjusted using the direct method of
the person was born in, or ever lived in, Puerto Rico. The study did standardization to the 2000 US standard population, distribution #1
not include deaths that occurred in Puerto Rico, in light of the under- (Klein & Schoenborn, 2001). Age-adjusted rates, 95% Confidence Inter-
reporting of drug overdose deaths in Puerto Rico (Senado de Puerto vals (CIs; with modified gamma intervals; Consonni, Coviello, Buzzoni
Rico, 2020). Members of the Senate of Puerto Rico have acknowledged & Mensi, 2012), and directly standardized rate ratios (SRRs) were calcu-
the lack of reliable counts of drug overdose deaths occurring in Puerto lated with the user-written program distrate (Coviello, 2006). An SRR is
Rico in the absence of a comprehensive surveillance system (Senado de the ratio of two directly age-standardized rates; when the 95% CI of the
Puerto Rico, 2020), complicated by backlogs in pending death investi- SRR includes a value of one, the two rates are not significantly different
gations in the aftermath of Hurricane Maria (Torres Gotay, 2019). at the 𝛼=0.05 level (Boyle & Parkin, 1991). For post-hoc comparisons of
rates for which SRRs were not calculated, a two-sided z test was utilized
to determine significance of differences at the 𝛼=0.05 level (Murphy, Xu
Measures
& Kochanek, 2013).

Demographic variables included the decedent’s sex (male/female,


Trend analysis
as identified on the death certificate), state of residence at time
Joinpoint Regression (version 4.7.0.0; National Cancer Insti-
of death, and age at time of death (re-coded into intervals 0–14,
tute, 2019) was utilized to examine trends in age-adjusted drug over-
15–24, 35–44, 45–54, 55–64, 65+). Drugs involved in the overdose
dose mortality rates over the period of 2009–2018 for NH White and
were determined based on ICD-10 codes listed as multiple causes
Puerto Rican-heritage men and women. Joinpoint Regression identifies
of death: T40.1, heroin; T40.2, natural/semi-synthetic opioids (e.g.,
points of change in trends (i.e., joinpoints), using Monte Carlo simu-
oxycodone, codeine, morphine); T40.4, synthetic opioids excluding
lations to determine the model with the best-fitting set of joinpoints
methadone; T40.5, cocaine; T42.4, benzodiazepines; and T43.6, psy-
(Kim, Fay, Feuer & Midthune, 2000). The Joinpoint Regression software
chostimulants with abuse potential, excluding cocaine. The ICD-10
also calculates annual percent change for each segment of a trend, in a
category T40.4 (“synthetic opioids”) encompasses fentanyl, fentanyl
log-linear model (National Cancer Institute, 2019). In the present study,
analogues, and other synthetic opioids except methadone; in recent
Joinpoint Regression was used to characterize trends in each group (NH
years, the majority of deaths in this category have been attributed
White men, Puerto Rican-heritage men, NH White women, and Puerto
to illicitly-manufactured fentanyl (Gladden, Martinez & Seth, 2016).
Rican-heritage women) individually. In supplemental analyses, trends
The ICD-10 category T43.6 (“psychostimulants with abuse potential”)
were also examined for overdose deaths specifically involving heroin,
excludes cocaine but includes methamphetamine, amphetamines, 3,4-
“synthetic opioids excluding methadone,” and natural/semi-synthetic
Methylenedioxymethamphetamine (MDMA/Ecstasy), methylphenidate
opioids.
(Ritalin) and caffeine (Kariisa, Scholl, Wilson, Seth & Hoots, 2019);
overdose deaths in this category generally involve methamphetamine
Sensitivity analyses
(Ossiander, 2014). The majority of drug overdose deaths involve mul-
In consideration of variation in population estimates, especially for
tiple substances (Martins, Sampson, Cerdá & Galea, 2015), and each
relatively small subgroups, age-adjusted drug overdose mortality rates
death certificate may list more than one drug. Therefore, mortality rates
were also calculated using population estimates from full 2018 Amer-
for different types of drugs are not mutually-exclusive; for example, an
ican Community Survey (ACS) data, for Puerto Rican and NH White
overdose death involving heroin and cocaine would be included both in
individuals overall and by state. In order to compare the rates cal-
the heroin-involved overdose mortality rate and the cocaine-involved
culated with IPUMS (the 1% random, representative sample from the
overdose mortality rate.
ACS) versus rates calculated with full ACS population estimates, all were
age-adjusted using distribution #4 of the 2000 US standard population
Analyses (Klein & Schoenborn, 2001), as full ACS population estimates for in-
dividuals of Puerto Rican heritage were only viewable for broader age
Drug overdose mortality rates categories. Finally, the age-adjusted rates for NH White individuals cal-
Analyses were completed in Stata/MP 16. Age-specific drug over- culated in the present study, using population estimates from IPUMS,
dose mortality rates were calculated for Puerto Rican-heritage and NH were compared against the age-adjusted rates for NH White individuals
White individuals for 2018, and age-adjusted drug overdose mortal- calculated by CDC’s online platform with bridged-race postcensal esti-
ity rates were calculated for these groups overall and by sex, spe- mates (CDC, 2020a).
cific drug involved in overdose, and state of residence. State-level rates
were available only for states with more than 20 Puerto Rican-heritage Results
drug overdose decedents recorded in 2018, due to reliability concerns
(CDC, 2020a). In consideration of regional variations in drug supplies, Puerto Rican heritage compared to NH White
supplemental state-level mortality rates were also calculated specifi-
cally for overdoses involving the category “synthetic opioids excluding As presented in Table 1, the 2018 age-adjusted drug overdose mor-
methadone.” Finally, annual age-adjusted drug overdose mortality rates tality rate was 10% higher in Puerto Rican-heritage than NH White
were calculated for each year from 2009 to 2018 for NH White and individuals (28.73 per 100,000 vs. 26.15 per 100,000, respectively).
Puerto Rican-heritage men and women. The age-adjusted drug overdose mortality rate was 33% higher in
Although CDC utilizes US Census Bureau bridged-race postcensal es- Puerto Rican-heritage men than NH White men (45.21 vs. 34.07, per
timates for population denominators in rate calculation (CDC, 2020a), 100,000), yet 31% lower in Puerto Rican-heritage women than NH
these population estimates are not available for Puerto Rican heritage. White women (12.53 vs. 18.11, per 100,000). When considering specific
In the present study, therefore, population estimates were obtained drugs, age-adjusted overdose mortality rates were significantly higher
from the Integrated Public Use Microdata Series (IPUMS; Ruggles et al., among Puerto Rican-heritage individuals than NH White individuals
2020), a weighted, random sample of 1% of the US Census Bureau’s for deaths involving “synthetic opioids excluding methadone” (53%

3
M. Cano and C. Gelpí-Acosta International Journal of Drug Policy 90 (2021) 103079

Table 1
Age-adjusted drug overdose mortality rates, and directly standardized rate ratios (SRR), for Puerto Rican (PR)-
heritage and Non-Hispanic (NH) White decedents in the United States in 2018, overall and by sex, drug, and state.

Age-adjusted drug overdose mortality rate, SRR (95% CI) Ratio of


per 100,000 (95% CI) PR-heritage to NH White

Characteristic PR-Heritage NH White

Overall 28.73 (27.31–30.21) 26.15 (25.91–26.39) 1.10 (1.04–1.16)


By Sex
Male 45.21 (42.67–47.86) 34.07 (33.69–34.45) 1.33 (1.25–1.41)
Female 12.53 (11.25–13.93) 18.11 (17.83–18.39) 0.69 (0.62–0.77)
By Drug
Synthetic opioids 19.60 (18.43–20.83) 12.84 (12.67–13.01) 1.53 (1.43–1.62)
Heroin 10.02 (9.19–10.91) 5.93 (5.82–6.05) 1.69 (1.55–1.84)
Natural/semisynthetic opioids 4.28 (3.75–4.88) 5.10 (5.00–5.20) 0.84 (0.73–0.96)
Cocaine 10.01 (9.18–10.89) 4.71 (4.61–4.81) 2.12 (1.94–2.32)
Psychostimulants 1.32 (1.04–1.66) 5.11 (5.01–5.22) 0.26 (0.20–0.33)
Benzodiazepines 4.32 (3.78–4.92) 4.65 (4.56–4.75) 0.93 (0.81–1.06)
By State
Connecticut 38.41 (31.29–46.78) 37.83 (35.16–40.64) 1.02 (0.82–1.25)
Florida 20.16 (17.64–22.94) 36.65 (35.42–37.92) 0.55 (0.48–0.63)
Illinois 32.34 (24.72–41.59) 22.84 (21.73–23.99) 1.42 (1.08–1.83)
Massachusetts 49.31 (41.71–58.04) 38.24 (36.42–40.12) 1.29 (1.08–1.53)
New Jersey 52.85 (46.29–60.09) 44.99 (42.95–47.11) 1.17 (1.02–1.35)
New York 26.42 (23.36–29.76) 22.73 (21.79–23.69) 1.16 (1.02–1.32)
North Carolina 18.73 (11.48–29.44) 29.35 (27.98–30.77) 0.64 (0.39–1.01)
Ohio 34.53 (24.90–47.16) 39.02 (37.67–40.40) 0.88 (0.64–1.21)
Pennsylvania 55.62 (48.65–63.38) 39.34 (38.01–40.71) 1.41 (1.23–1.62)

Note. SRRs in bold indicate that the ratio of the directly age-standardized drug overdose mortality rates of Puerto
Rican-heritage individuals to NH Whites is statistically significantly different from one (𝛼=0.05). An SRR greater
than one would be observed when the rate in Puerto Rican-heritage individuals is higher than in NH-Whites; an
SRR lower than one would be observed when the rate in Puerto Rican-heritage individuals is lower than in NH-
Whites. Puerto Rican heritage is independent of birthplace. Rate numerators obtained from the Multiple Cause
of Death dataset; rate denominators obtained from IPUMS (Ruggles et al., 2020). Rates were age-adjusted using
distribution #1 of the 2000 US standard population (Klein & Schoenborn, 2001). Number of drug overdose deaths in
50 states/DC in 2018: 1560 among PR-Heritage and 49,922 among NH-Whites. Drug involvement is not mutually-
exclusive, as each death may involve more than one drug type. Abbreviations. PR, Puerto Rican; NH, Non-Hispanic;
SRR, directly standardized rate ratio; CI, confidence interval.

Fig. 1. Age-specific drug-overdose mortality rates for Puerto Rican-heritage and Non-Hispanic White individuals in the United States in 2018, overall and by sex.
Note: Figures along the x axis represent age categories (ages 0 to 14 years not depicted due to reliability concerns with rates computed from small numbers). Puerto
Rican refers to identified heritage, regardless of place of birth. Source: Rate numerators from Multiple Cause of Death file; denominators from IPUMS population
estimates (Ruggles et al., 2020) from the 2018 American Community Survey. Abbreviations. NH, Non-Hispanic.

higher), heroin (69% higher), and cocaine (112% higher), yet lower mortality rate among Puerto Rican-heritage individuals was observed
for natural/semisynthetic opioids (e.g., oxycodone, codeine, morphine; in Pennsylvania (55.62 per 100,000), followed by New Jersey (52.85
16% lower) and “psychostimulants excluding cocaine” (e.g., metham- per 100,000) and Massachusetts (49.31 per 100,000). State-level age-
phetamine; 74% lower). adjusted mortality rates for overdoses involving “synthetic opioids ex-
State-level results were available for nine states. The 2018 age- cluding methadone” are provided in Supplemental Table 1.
adjusted drug overdose mortality rate was significantly higher among When disaggregated by sex and age group (Fig. 1), 2018 drug over-
Puerto Rican-heritage individuals than NH White individuals in Penn- dose mortality rates were significantly higher among NH White men
sylvania, Illinois, Massachusetts, New Jersey, and New York, yet the ages 15–24 and 25–34, compared to Puerto Rican-heritage men; con-
opposite was observed in Florida. The highest 2018 drug overdose versely, rates in ages 35–44, 45–54, 55–64, and 65+ were significantly

4
M. Cano and C. Gelpí-Acosta International Journal of Drug Policy 90 (2021) 103079

Fig. 2. Age-adjusted drug overdose mortality rates for Non-Hispanic


White and Puerto Rican-heritage individuals in the US, 2009–2018, by
sex.
Note: Point estimates plotted with 95% confidence intervals. Puerto
Rican applies to the identification of decedents’ heritage, regardless
of birthplace. Abbreviations. NH, Non-Hispanic. Source. Death counts
from Multiple Cause of Death data; population estimates from IPUMS
(Ruggles et al., 2020). Age-adjusted to the 2000 US standard popula-
tion.

higher in Puerto Rican-heritage men than NH White men. Drug overdose time period of 2009–2018, with an annual percent change (APC) of
mortality rates were higher in NH White women than Puerto Rican- 15.6. For NH White men, the trend from 2009 to 2018 was also pos-
heritage women in all age groups, with the exception of the 55–64 itive (p<0.001), with an APC of 8.7. For Puerto Rican-heritage women,
group, in which no significant difference was observed. The highest drug the annual percent change from 2009 to 2014 did not significantly differ
overdose mortality rate, by age group, sex, and heritage, was observed from zero, while a significant (p<0.001) increasing trend was observed
in Puerto Rican-heritage men ages 45–54 (104.14 per 100,000). from 2014 to 2018, with an APC of 14.5. Among NH White women, a
significantly (p<0.001) increasing trend was observed over the entire
time period of 2009–2018, with an APC of 5.7. In Supplemental Fig-
Drug overdose mortality over time
ure 1, trends are also depicted for overdose mortality rates involving
heroin, natural/semi-synthetic opioids, and “synthetic opioids exclud-
Fig. 2 depicts age-adjusted drug overdose mortality rates for NH
ing methadone.”
White and Puerto Rican-heritage men and women over the course of
ten years, from 2009 to 2018. Age-adjusted drug overdose mortality
rates were higher in NH White men than Puerto Rican-heritage men in Sensitivity analyses
2009–2011; rates did not significantly differ between these two groups
in 2012–2014, and rates in Puerto Rican-heritage men exceeded rates When comparing rates based on IPUMS versus full ACS population
in NH White men from 2015 to 2018. Over the period of 2009–2018, estimates (with age-adjustment to distribution #4 of the 2000 US stan-
age-adjusted drug overdose mortality rates nearly doubled among NH dard population), point estimates and 95% CIs differed slightly, ranging
White men (from 18.29 to 34.07, per 100,000) and nearly tripled among from 27.80 (95% CI, 26.44–29.22) versus 27.82 (95% CI, 26.45–29.24)
Puerto Rican-heritage men (from 15.35 to 45.21, per 100,000). Among for the overall rate in Puerto Rican heritage, to 32.41 (95% CI, 23.40–
women, age-adjusted drug overdose mortality rates doubled in Puerto 44.53) versus 34.00 (95% CI, 24.51–46.49) for Puerto Rican heritage
Rican-heritage women from 2009 to 2018, from 6.00 to 12.53 per in Ohio. Nonetheless, the direction and significance of the standard-
100,000, while rising from 11.61 to 18.11 per 100,000 in NH White ized rate ratios (SRR) were consistent when rates were calculated with
women; age adjusted drug overdose mortality rates were significantly IPUMS, versus full ACS data, for overall rates and rates by state, with
lower for women of Puerto Rican-heritage, compared to NH White the exception of New Jersey (SRR 1.16 [95% CI, 1.01–1.33], versus 1.13
women, each year from 2009 to 2018. [95% CI, 0.98–1.30]).
Results of Joinpoint Regression (not depicted in Fig. 2) indicated Finally, when comparing age-adjusted drug overdose rates for NH
that, for Puerto Rican-heritage men, a significant (p<0.001) positive Hispanic Whites based on population estimates from IPUMS versus age-
trend in drug overdose mortality rates was observed over the entire adjusted rates from CDC’s online query with bridged-race postcensal

5
M. Cano and C. Gelpí-Acosta International Journal of Drug Policy 90 (2021) 103079

estimates, slight differences were noted based on the different pop- major contributors to fatal overdoses among stateside Puerto Ricans,
ulation estimates used in denominators (e.g., 26.15 [95% CI, 25.91– and disparate rates of drug overdose mortality relative to NH Whites
26.39] versus 25.73 [95% CI, 25.50–25.97] for NH Whites overall, per have persisted from 2015 to 2018 in Puerto Rican-heritage men.
100,000). Because all rates presented in the main analyses of the present
study utilized population estimates from the same source (IPUMS), this Geography and drug supplies
is not a concern when comparing rates within the study but precludes
comparisons to other published rates calculated with bridged-race post- Overall, the elevated rates of drug overdose mortality among state-
censal estimates. side Puerto Ricans may partially reflect the intersection of geographic
settlement patterns and geographic variation in drug supplies. Illicitly-
Limitations manufactured fentanyl is highly-prevalent in the heroin supplies of the
Northeastern US (Ciccarone, Ondocsin & Mars, 2017), where many
Rates calculated for Puerto Rican-heritage individuals in the present Puerto Rican communities are located. “Speedballs” (concurrent use of
study may be underestimates, due to under-ascertainment of ethnicity heroin and cocaine) may multiply risk of exposure to fentanyl, as fen-
on the death certificate, and the level of under-classification of Puerto tanyl may be present in the heroin and/or in the cocaine used in a
Rican heritage may have varied by factors such as place of birth, region speedball. Numerous studies document speedball use among stateside
of residence (Arias et al., 2016), or whether the decedent had local fam- Puerto Ricans who use drugs (Arasteh, Des Jarlais, Feelemyer, & McK-
ily/friends to provide information to the funeral director. An analysis night, 2020; Deren, Kang, Mino & Guarino, 2012; Gelpí-Acosta et al.,
of race/ethnicity reporting on death certificates from 1999 to 2011 es- 2011, 2016); among a sample of Puerto Rican migrants with injection
timated 83.5% sensitivity of Puerto Rican heritage classification on the drug use in New York City, more than 90% reported injecting speedballs
death certificate, relative to self-report classification (Arias et al., 2016). (Gelpí-Acosta et al., 2019).
Since bridged-race intercensal population estimates are not pro- The dangers of illicitly-manufactured fentanyl may explain the
vided for Puerto Rican heritage, the present study utilized IPUMS data, study’s findings that the age-adjusted drug overdose mortality rate in
a weighted, representative sample of 1% of data from the US Cen- Puerto Rican-heritage men doubled from 2013 to 2018 (from 22.6 to
sus Bureau’s ACS. Population estimates are subject to sampling error 45.2 per 100,000) and began to exceed the rates in NH White men in
(Spielman, Folch & Nagle, 2014), and the 2018 ACS estimates for Puerto 2015. The saturation of fentanyl in US underground drug markets began
Rican populations may not have fully reflected the post-Hurricane Maria around 2013 (Ciccarone, 2017) and was a notable contributor to over-
return migration to Puerto Rico during 2018 (Schachter & Bruce, 2020). dose mortality in cities such as New York City by 2015 (Nolan, Shama-
In the present study, rates calculated for small subgroups (e.g., by state) sunder, Colon-Berezin, Kunins & Paone, 2019). Illicitly-manufactured
included relatively large variance estimates, and state-level rates were fentanyl in regional drug supplies may partially account for the ele-
only available for nine states due to relatively small numbers of deaths vated drug overdose mortality rates observed in the present study among
in other states. Puerto Rican-heritage individuals in states such as Pennsylvania (55.6
Drug-specific overdose mortality rates are limited by under- per 100,000), New Jersey (52.9 per 100,000), Massachusetts (49.3 per
classification of drugs on death certificates (Slavova et al., 2015), as 100,000), Connecticut (38.4 per 100,000), Illinois (32.3 per 100,000),
well as the potential for misclassification of involvement of certain drugs and New York (26.4 per 100,000). In several of these states (Pennsylva-
(Mertz, Janssen & Williams, 2014). In 2018, 8% of drug overdose deaths nia, New Jersey, Massachusetts, Illinois, and New York), drug overdose
in the US did not specify involvement of any specific drug on the death mortality rates among Puerto Rican-heritage individuals were higher
certificate (Wilson, Kariisa, Seth, Smith & Davis, 2020), and the com- than among NH Whites; inequity and unequal access to effective ser-
pleteness of drug reporting varies widely along demographic and ge- vices likely contribute to these disparities.
ographic lines (Boslett, Denham, Hill & Adams, 2019; Jones, Warner,
Hedegaard & Compton, 2019; Slavova et al., 2015; Tote, Bradley, Mar- Drug overdose mortality by sex
tin, Yucel & Rosenberg, 2019).
A variety of demographic and contextual factors of interest and rel- In the present study, drug overdose mortality rates among stateside
evance (e.g., socioeconomics, mode of drug administration, access to Puerto Ricans were more than three and a half times as high in men as
treatment or harm reduction services) are not available in the death in women. Drug overdose mortality is higher among males than females
certificate data utilized in the study, limiting the scope of the analyses. in the US overall (Hedegaard, Miniño & Warner, 2020), yet results of the
Moreover, the mortality data in the present study do not provide infor- present study suggest that this sex difference is even more pronounced
mation regarding language use or proficiency, acculturation, or recency among stateside Puerto Ricans. In studies in Puerto Rico, Massachusetts,
of stateside migration, all of which are relevant factors when considering and New York City, approximately 80–90% of Puerto Rican partici-
the diversity of stateside Puerto Rican communities. Interpretations of pants who use drugs identify as male (Abadie et al., 2016; Coronado-
the nationwide findings in the present study are limited, considering that García et al., 2017; Thrash et al., 2018; Zerden et al., 2010). Despite
literature on the overdose vulnerabilities of Puerto Rican-heritage indi- comparatively lower drug overdose mortality rates among Puerto Rican-
viduals who use drugs has been based on regional samples (Colon et al., heritage women, in the present study the overall age-adjusted drug over-
2006; Deren et al., 2007; Gelpí-Acosta et al., 2019; Zerden, Marilis López dose mortality rate among Puerto Rican-heritage women more than
& Lundgren, 2010). The present study represented a first step in identi- doubled from 2009 to 2018, representing an ever-increasing concern.
fying disparities in drug overdose mortality rates among Puerto Rican- Moreover, while Puerto Rican-heritage and NH White men, as well as
heritage communities nationwide, yet an examination of the reasons for NH White women, evidenced a decline in drug overdose mortality rates
these disparities was beyond the scope of the study. from 2017 to 2018 (the two most recent years of data), no decline was
observed among Puerto Rican-heritage women.
Discussion
Drug overdose mortality by age
Study findings highlight the disproportionately high burden of drug
overdose mortality in stateside Puerto Rican populations. The highest Results of the study indicated that drug overdose mortality rates
drug overdose mortality rates among Puerto Rican-heritage individuals were highest among relatively older Puerto Rican-heritage individuals,
were observed among those identified as male, as well as those between in contrast to the age pattern observed among NH Whites. Among Puerto
the ages of 45–54 and those residing in several Northeastern states. The Rican-heritage men, the highest drug overdose mortality rate was ob-
study’s results emphasize that synthetic opioids, heroin, and cocaine are served in ages 45–54, concordant with research from New York City,

6
M. Cano and C. Gelpí-Acosta International Journal of Drug Policy 90 (2021) 103079

where the highest opioid overdose rates among Hispanics were observed experiences with and perceptions of overdose prevention tools such as
among middle-age/older adults (Allen, Nolan, Kunins & Paone, 2019). naloxone is therefore also crucial to identify intervention targets to save
Elevated rates of drug overdose mortality in this age group may reflect lives.
health vulnerabilities associated with relatively older age (Han, Tua-
zon, Kunins, Mantha & Paone, 2019), as well as risk factors such as Funding sources
lengthy injection drug use trajectories, high frequency of daily injec-
tion/polydrug injection, and poor opioid agonist therapy enrollment None.
and adherence, as observed in recent samples of Puerto Ricans who
inject drugs in New York City, many of whom were over 40 years old
Declarations of Interest
(Arasteh et al., 2020; Gelpí-Acosta et al., 2016, 2019). Engaging middle-
age/older Puerto Ricans who use drugs in harm reduction and overdose
We have no known conflict of interest to disclose.
prevention (Rhodes, 2009; Sherman et al., 2009) remains an urgent pri-
ority.
Supplementary materials
Implications
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.drugpo.2020.103079.
Overall, the study’s findings underscore the necessity of policies,
programs, and interventions to mitigate fatal drug overdose risk in
References
stateside Puerto Rican communities, as well as on the island of Puerto
Rico, where many individuals may have initiated drug use and formed Abadie, R., Gelpí-Acosta, C., Davila, C., Rivera, A., Welch-Lazoritz, M., & Dom-
practices and attitudes regarding drug use and harm reduction (Gelpí- browski, K. (2018). It Ruined My Life”: The effects of the War on Drugs on people
Acosta et al., 2019). In Puerto Rico, surveillance of drug overdose is who inject drugs (PWID) in rural Puerto Rico. International Journal of Drug Policy, 51,
121–127.
currently critically limited (Senado de Puerto Rico, 2020) yet much Abadie, R., Welch-Lazoritz, M., Gelpi-Acosta, C., Reyes, J. C., & Dombrowski, K. (2016).
needed (Torres Gotay, 2019). Policies, programs, and funding are also Understanding differences in HIV/HCV prevalence according to differentiated risk
necessary to address the insufficient access to harm reduction tools and behaviors in a sample of PWID in rural Puerto Rico. Harm Reduction Journal, 13(1),
10.
medication-assisted treatment in Puerto Rico (Des Jarlais et al., 2015; Alegría, M., Canino, G., Shrout, P. E., Woo, M., Duan, N., Vila, D., et al. (2008). Prevalence
Gelpí-Acosta et al., 2019; Welch-Lazoritz et al., 2017) and the risk envi- of mental illness in immigrant and non-immigrant U.S. Latino groups. The American
ronment associated with the criminal justice system (e.g., drug sentenc- Journal of Psychiatry, 165(3), 359–369. 10.1176/appi.ajp.2007.07040704.
Alegría, M., Mulvaney-Day, N., Torres, M., Polo, A., Cao, Z., & Canino, G. (2007). Preva-
ing, injection drug use in prisons, and the lack of medication-assisted
lence of psychiatric disorders across Latino subgroups in the United States. American
treatment in prisons; Abadie et al., 2018). Journal of Public Health, 97(1), 68–75. 10.2105/AJPH.2006.087205.
In the 50 states/DC, policies, programs, and initiatives are needed to Allen, B., Nolan, M. L., Kunins, H. V., & Paone, D. (2019). Racial differences in opioid
address underlying social and economic determinants (Dasgupta et al., overdose deaths in New York City, 2017. JAMA Internal Medicine, 179(4), 576–578.
Arasteh, K., Des Jarlais, D. C., Feelemyer, J., & McKnight, C. (2020). Hepatitis C incidence
2018) and inequalities that exacerbate risk in Puerto Rican com- and prevalence among Puerto Rican people who use drugs in New York City. Global
munities, such as poverty, racism, structural discrimination, stigma, Public Health, 15(12), 1789–1799. 10.1080/17441692.2020.1768276.
unmet physical and mental health needs (Beletsky & Davis, 2017), Arellano-Morales, L., Roesch, S. C., Gallo, L. C., Emory, K. T., Molina, K. M., Gonzalez, P.,
et al. (2015). Prevalence and Correlates of Perceived Ethnic Discrimination in the
and residential segregation. Harm reduction interventions targeted Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study.
to address the “opioid epidemic” may need to become more ver- Journal of Latina/o Psychology, 3(3), 160–176.
satile and incorporate culturally-appropriate—in fact, Puerto Rico- Arias, E., Heron, M. P., & Hakes, J. K. (2016). The validity of race and Hispanic-origin re-
porting on death certificates in the United States: An update. Vital and Health Statistics,
appropriate—education and prevention initiatives. Ethnographic re- Series, 2(172), 1–21 Hyattsville, MD: National Center for Health Statistics.
search with Puerto Rican migrants in New York City highlights the Beletsky, L., & Davis, C. S. (2017). Today’s fentanyl crisis: Prohibition’s Iron Law, revisited.
potential benefits of sourcing harm reduction education and provi- International Journal of Drug Policy, 46, 156–159.
Boslett, A. J., Denham, A., Hill, E. L., & Adams, M. C. B. (2019). Unclassified drug overdose
sion from within the community, built on the trust, shared experi- deaths in the opioid crisis: Emerging patterns of inequity. Journal of the American
ences, expectations, and formal or informal roles within the group Medical Informatics Association, 26(8–9), 767–777. 10.1093/jamia/ocz050.
(Gelpí-Acosta, Guarino, Benoit, Deren & Rodríguez, 2020). Culturally- Boyle, P., & Parkin, D. M. (1991). Statistical methods for registries. In O. M. Jensen,
D. M. Parkin, R. MacLennan, C. S. Muir, & R. G. Skeet (Eds.), Cancer registration:
customized, peer-driven interventions for HIV prevention have been tar-
Principles and methods, IARC scientific publication no. 95 (pp. 126–158). Lyon, France:
geted to Puerto Rican-born individuals who inject drugs, capitalizing on International Agency for Research on Cancer.
the potential of individuals who use drugs to promote safer practices Brooks, E. G., & Reed, K. D. (2015). Principles and pitfalls: A guide to death certification.
from within their community and social networks (Deren et al., 2012); Clinical Medicine & Research, 13(2), 74–82. 10.3121/cmr.2015.1276.
Burgos, G., & Rivera, F. I. (2012). Residential segregation, socio-economic status, and
such approaches may be adapted and expanded for overdose prevention disability: A multi-level study of Puerto Ricans in the United States. Centro Journal,
education and naloxone distribution. Community-led research can iden- 24(2), 14–47.
tify otherwise-overlooked organic pathways to health promotion and Cano, M. (2020). Drug overdose deaths among US Hispanics: Trends (2000-2017) and
recent patterns. Substance Use & Misuse. 10.1080/10826084.2020.1793367.
maintenance among Puerto Rican individuals who use drugs. Identify- Capielo Rosario, C., Schaefer, A., Ballesteros, J., Rentería, R., & David, E. J. R. (2019). A
ing overdose-protective factors among Puerto Rican individuals who use caballo regalao no se le mira el colmillo: Colonial mentality and Puerto Rican depres-
drugs, and perhaps in particular among Puerto Rican women, can inform sion. Journal of Counseling Psychology, 66(4), 396–408.
Centers for Disease Control and Prevention. (2020a). Multiple cause of death 1999-2018.
a grounded overdose prevention action plan for this community. Retrieved from https://wonder.cdc.gov/mcd.html
Undoubtedly, more research is needed to understand the mecha- Centers for Disease Control and Prevention. (2020b, March). Understanding the epidemic.
nisms behind the profound disparities documented in the present study. Retrieved from https://www.cdc.gov/drugoverdose/epidemic/index.html
Ciccarone, D. (2017). Fentanyl in the US heroin supply: A rapidly changing risk environ-
For instance, we lack socioeconomic indicators, medical data relevant to
ment. International Journal of Drug Policy, 46, 107–111.
overdose vulnerability (e.g., heart and respiratory conditions), and data Ciccarone, D. (2019). The triple wave epidemic: Supply and demand drivers of the US
on drug use trajectories across geographies, including length of drug opioid overdose crisis. International Journal of Drug Policy, 71, 183–188.
Ciccarone, D., Ondocsin, J., & Mars, S. G. (2017). Heroin uncertainties: Exploring users’
use and whether individuals ever injected drugs in Puerto Rico—an im-
perceptions of fentanyl-adulterated and-substituted ‘heroin’. International Journal of
portant factor since Puerto Rico is an environment that shapes risky Drug Policy, 46, 146–155.
injection subjectivities (Gelpí-Acosta et al., 2019). These data gaps limit Colon, H. M., Deren, S., Robles, R. R., Kang, S. Y., Cabassa, M., & Sahai, H. (2006). A com-
our ability to fully comprehend the overdose outcomes presented in this parative study of mortality among Puerto Rican injection drug users in East Harlem,
New York, and Bayamon, Puerto Rico. Journal of Urban Health, 83(6), 1114–1126.
study. Across the US, naloxone access and use in Puerto Rican commu- Consonni, D., Coviello, E., Buzzoni, C., & Mensi, C. (2012). A command to calculate age-s-
nities is also understudied. An understanding of stateside Puerto Ricans’ tandardized rates with efficient interval estimation. The Stata Journal, 12(4), 688–701.

7
M. Cano and C. Gelpí-Acosta International Journal of Drug Policy 90 (2021) 103079

Coronado-García, M., Thrash, C. R., Welch-Lazoritz, M., Gauthier, R., Reyes, J. C., Martins, S. S., Sampson, L., Cerdá, M., & Galea, S. (2015). Worldwide prevalence and
Khan, B., et al. (2017). Using network sampling and recruitment data to understand trends in unintentional drug overdose: A systematic review of the literature. American
social structures related to community health in a population of people who inject Journal of Public Health, 105(11), e29–e49.
drugs in rural Puerto Rico. Puerto Rico Health Sciences Journal, 36(2), 77. Mertz, K. J., Janssen, J. K., & Williams, K. E. (2014). Underrepresentation of heroin in-
Coviello, E. (2006). DISTRATE: Stata module to compute direct stan- volvement in unintentional drug overdose deaths in Allegheny County, PA. Journal of
dardized rates with improved confidence interval. Retrieved from Forensic Sciences, 59(6), 1583–1585.
http://ideas.repec.org/c/boc/bocode/s456708.html Mora, M. T., Dávila, A., & Rodríguez, H. (2018). Migration, geographic destinations, and
Dasgupta, N., Beletsky, L., & Ciccarone, D. (2018). Opioid crisis: No easy fix to its social socioeconomic outcomes of Puerto Ricans during la crisis Boricua: Implications for
and economic determinants. American Journal of Public Health, 108(2), 182–186. island and stateside communities post-maria. Centro Journal, 30(3), 208–229.
Deren, S., Gelpí-Acosta, C., Albizu-García, C. E., González, Á., Des Jarlais, D. C., & Murphy, S. L., Xu, J., & Kochanek, K. D. (2013). Deaths: Final data for 2010. National Vital
Santiago-Negrón, S. (2014). Addressing the HIV/AIDS epidemic among Puerto Ri- Statistics Reports vol 61 no 4. Hyattsville, MD: National Center for Health Statistics.
can people who inject drugs: The need for a multiregion approach. American Journal National Cancer Institute. (2019). Joinpoint regression program, version 4.7.0.0. Re-
of Public Health, 104(11), 2030–2036. 10.2105/AJPH.2014.302114. trieved from https://surveillance.cancer.gov/help/joinpoint.
Deren, S., Kang, S. Y., Colón, H. M., & Robles, R. R. (2007). The Puerto Rico–New York Noe-Bustamante, L., Flores, A., & Shah, S. (2019). Facts on Hispanics of Puerto Rican
airbridge for drug users: Description and relationship to HIV risk behaviors. Journal origin in the United States, 2017. Pew Research Center. Retrieved from https://www.
of Urban Health, 84(2), 243–254. pewresearch.org/hispanic/fact-sheet/u-s-hispanics-facts-on-puerto-rican-origin-
Deren, S., Kang, S. Y., Mino, M., & Guarino, H. (2012). Conducting peer outreach to mi- latinos/.
grants: Outcomes for drug treatment patients. Journal of Immigrant and Minority Health, Nolan, M. L., Shamasunder, S., Colon-Berezin, C., Kunins, H. V., & Paone, D. (2019). In-
14(2), 251–258. creased presence of fentanyl in cocaine-involved fatal overdoses: Implications for pre-
Des Jarlais, C. D., Nugent, A., Solberg, A., Feelemyer, J., Mermin, J., & Holtz- vention. Journal of Urban Health, 96(1), 49–54.
man, D. (2015). Syringe service programs for persons who inject drugs in urban, sub- Ossiander, E. M. (2014). Using textual cause-of-death data to study drug poisoning deaths.
urban, and rural areas—United States, 2013. Morbidity and Mortality Weekly Report, American Journal of Epidemiology, 179(7), 884–894.
64(48), 1337–1341. Pérez, D. J., Fortuna, L., & Alegria, M. (2008). Prevalence and correlates of everyday
Friedman, J., Karandinos, G., Hart, L. K., Castrillo, F. M., Graetz, N., & Bourgois, P. (2019). discrimination among US Latinos. Journal of Community Psychology, 36(4), 421–433.
Structural vulnerability to narcotics-driven firearm violence: An ethnographic and Rhodes, T. (2009). Risk environments and drug harms: A social science for harm reduction
epidemiological study of Philadelphia’s Puerto Rican inner-city. PloS one, 14(11). approach. International Journal of Drug Policy, 20(3), 193–201.
Gelpí-Acosta, C., Guarino, H., Benoit, E., Deren, S., Pouget, E. R., & Rodríguez, A. (2019). Rosenblum, D., Castrillo, F. M., Bourgois, P., Mars, S., Karandinos, G., Unick, G. J.,
Injection risk norms and practices among migrant Puerto Rican people who inject et al. (2014). Urban segregation and the US heroin market: A quantitative model
drugs in New York City: The limits of acculturation theory. International Journal of of anthropological hypotheses from an inner-city drug market. International Journal
Drug Policy, 69, 60–69. of Drug Policy, 25(3), 543–555.
Gelpí-Acosta, C., Guarino, H., Benoit, E., Deren, S., & Rodríguez, A. (2020b). Toward Ruggles, S., Flood, S., Goeken, R., Grover, J., Meyer, E., Pacas, J., et al..
community empowerment: The Puerto Rican ganchero. Contemporary Drug Problems, 10.18128/D010.V10.0.
1-20. 10.1177/0091450920964576. Schachter, J., & Bruce, A. (2020, August 19). Estimating Puerto Rico’s popu-
Gelpí-Acosta, C., Hagan, H., Jenness, S. M., Wendel, T., & Neaigus, A. (2011). Sexual and lation after Hurricane Maria. Retrieved from https://www.census.gov/library/
injection-related risks in Puerto Rican-born injection drug users living in New York stories/2020/08/estimating-puerto-rico-population-after-hurricane-maria.html
City: A mixed-methods analysis. Harm Reduction Journal, 8(1), 28. Senado de Puerto Rico. (2020). P. del S. 1625. Retrieved from
Gelpí-Acosta, C., Pouget, E. R., Reilly, K. H., Hagan, H., Neaigus, A., Wendel, T., https://www.senado.pr.gov/Legislations/ps1625-20.pdf
et al. (2016). Time since migration and HIV risk behaviors among Puerto Ricans who Sherman, S. G., Gann, D. S., Tobin, K. E., Latkin, C. A., Welsh, C., & Bielenson, P. (2009).
inject drugs in New York City. Substance Use & Misuse, 51(7), 870–881. The life they save may be mine”: Diffusion of overdose prevention information from
Gelpí-Acosta, C., Rodríguez-Díaz, C. E., Aponte-Meléndez, Y., & Abadie, R. (2020a). Puerto a city sponsored programme. International Journal of Drug Policy, 20(2), 137–142.
Rican syndemics: Opiates, overdoses, HIV, and the Hepatitis C virus in a context of Shiels, M. S., Freedman, N. D., Thomas, D., & Berrington de Gonzalez, A. (2018). Trends in
ongoing crises. American Journal of Public Health. U.S. drug overdose deaths in non-Hispanic black, Hispanic, and non-Hispanic white
Gladden, R. M., Martinez, P., & Seth, P. (2016). Fentanyl law enforcement submissions persons, 2000–2015. Annals of Internal Medicine, 168(6), 453–455.
and increases in synthetic opioid–involved overdose deaths—27 states, 2013–2014. Slavova, S., O’Brien, D. B., Creppage, K., Dao, D., Fondario, A., Haile, E., et al. (2015).
Morbidity and Mortality Weekly Report, 65(33), 837–843. Drug overdose deaths: Let’s get specific. Public Health Reports, 130(4), 339–342.
Glassman, B. (2019). More Puerto Ricans move to mainland United States, poverty de- 10.1177/003335491513000411.
clines. U.S. Census Bureau. Retrieved from https://www.census.gov/library/stories/ Spielman, S. E., Folch, D., & Nagle, N. (2014). Patterns and causes of uncertainty in the
2019/09/puerto-rico-outmigration-increases-poverty-declines.html . American Community Survey. Applied Geography, 46, 147–157.
Han, B. H., Tuazon, E., Kunins, H. V., Mantha, S., & Paone, D. (2019). Unintentional drug Thrash, C., Welch-Lazoritz, M., Gauthier, G., Khan, B., Abadie, R., Dombrowski, K.,
overdose deaths involving cocaine among middle-aged and older adults in New York et al. (2018). Rural and urban injection drug use in Puerto Rico: Network implica-
City. Drug and Alcohol Dependence, 198, 121–125. tions for human immunodeficiency virus and hepatitis C virus infection. Journal of
Hautala, D., Abadie, R., Khan, B., & Dombrowski, K. (2017). Rural and urban comparisons Ethnicity in Substance Abuse, 1(2), 199–222.
of polysubstance use profiles and associated injection behaviors among people who Tkacik, C. (2019). The landanum evil. Maryland’s 19th century opiate epidemic. AP news
inject drugs in Puerto Rico. Drug and Alcohol Dependence, 181, 186–193. Retrieved from https://apnews.com/910654effffe42f985ebe01f299407f5 .
Hedegaard, H., Miniño, A. M., & Warner, M. (2020). Drug overdose deaths in the United Torres Gotay, B. (2019,. January). Alarman las muertes por sobredosis de opiáceos.
States, 1999-2018. Hyattsville, MD: National Center for Health Statistics NCHS Data Retrieved from http://www.iniciativacomunitaria.org/alarman-las-muertes-por-
Brief, no 356. sobredosis-de-opiaceos/?lang=en
Hoots, B., Vivolo‐Kantor, A., & Seth, P. (2020). The rise in non‐fatal and fatal overdoses Tote, K. M., Bradley, H., Martin, E. G., Yucel, R., & Rosenberg, E. S. (2019). Factors as-
involving stimulants with and without opioids in the United States. Addiction, 115(5), sociated with incomplete toxicology reporting in drug overdose deaths, 2010–2016.
946–958. 10.1111/add.14878. Annals of Epidemiology, 38, 65–69. 10.1016/j.annepidem.2019.08.006.
Jalal, H., Buchanich, J. M., Roberts, M. S., Balmert, L. C., Zhang, K., & Burke, D. S. (2018). U.S. Census Bureau. (n.d.). 2018 American Community Survey. Retrieved from
Changing dynamics of the drug overdose epidemic in the United States from 1979 data.census.gov
through 2016. Science, 361, 1–6. 10.1126/science.aau1184. Welch-Lazoritz, M., Habecker, P., Dombrowski, K., Villegas, A. R., Davila, C. A.,
Jones, C. M., Warner, M., Hedegaard, H., & Compton, W. (2019). Data quality consid- Colón, Y. R., et al. (2017). Differential access to syringe exchange and other pre-
erations when using county-level opioid overdose death rates to inform policy and vention activities among people who inject drugs in rural and urban areas of Puerto
practice. Drug and Alcohol Dependence, 204, Article 107549. Rico. International Journal of Drug Policy, 43, 16–22.
Kariisa, M., Scholl, L., Wilson, N., Seth, P., & Hoots, B. (2019). Drug overdose Wilson, N., Kariisa, M., Seth, P., Smith, H., IV, & Davis, N. L. (2020). Drug and opioid-in-
deaths involving cocaine and psychostimulants with abuse potential—United States, volved overdose deaths—United States, 2017–2018. Morbidity and Mortality Weekly
2003–2017. Morbidity and Mortality Weekly Report, 68(17), 388–395. Report, 69(11), 290–297.
Kim, H. J., Fay, M. P., Feuer, E. J., & Midthune, D. N. (2000). Permutation tests for join- Zerden, L. D. S., Marilis López, L., & Lundgren, L. M. (2010). Needle sharing among Puerto
point regression with applications to cancer rates. Statistics in Medicine, 19, 335–351. Rican injection drug users in Puerto Rico and Massachusetts: Place of birth and resi-
Klein, R. J., & Schoenborn, C. A. (2001). Age adjustment using the 2000 projected U.S. pop- dence matter. Substance Use & Misuse, 45(10), 1605–1622.
ulation. Healthy people statistical notes, no. 20. Hyattsville, MD: National Center for
Health Statistics.
Kolodny, A., Courtwright, D. T., Hwang, C. S., Kreiner, P., Eadie, J. L., Clark, T. W.,
et al. (2015). The prescription opioid and heroin crisis: A public health approach
to an epidemic of addiction. Annual Review of Public Health, 36, 559–574.

You might also like