Overlooked: Who suffers the most from the opioid epidemic in Minnesota?

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Opioids have killed more than 4,000 people in Minnesota over the past five years. 

Who are these Minnesotans? Sahan Journal looked at death records to determine which communities are most at risk. We confirmed that the problem is far worse for people of color in Minnesota. And, with new data and greater clarity, we’re showing how the disparities are impacting specific communities: From 2019 to 2023, Native Americans were at least 15 times more likely to die from opioid overdoses than white people. Somali Minnesotans were at least twice as likely to die from opioid overdose than their white counterparts. Latino Minnesotans were 1.5 times more likely to suffer fatal overdoses.

While early data show that deaths from overdoses stopped rising in 2023, the gaps grew between white Minnesotans and people of color. These racial death rate disparities are disturbing, but not surprising, to health practitioners and researchers. 

“In Minnesota, we are the worst,” said Dr. Kumi Smith, Ph.D., an epidemiologist at the University of Minnesota, who teaches public health classes and analyzes national data on opioid disparities. “We’re No. 1 in terms of Native-to-white disparities in fatal overdoses, by far.”

It’s too early to say whether the 2023 numbers signal a long-term plateau for the country, experts caution. In 2018, for example, national opioid deaths stalled and then climbed again. 

Smith points to several possible causes for stabilizing death rates. The wider availability of interventions may be preventing some deaths. These include the overdose medication Narcan, fentanyl test strips and substance-use education. Epidemiologists also point to the grim concept of “saturation”: At some point, most of the people who are vulnerable to overdose deaths have already succumbed. 

“It's too early to tell if the new data is a fluke or signals a longer-term trend,” she said.

Regardless, the national death rate is still 2.5 times higher than in 2011, when the Centers for Disease Control and Prevention declared opioid overdose deaths an epidemic.

“The numbers of deaths are still intolerably high,” she said. 

In our analysis of five years’ worth of state death records, we looked for trends within neighborhoods and communities. We also interviewed public-health officials, epidemiologists, doctors who specialize in addiction, harm-reduction advocates, community leaders and people who have battled addiction. This is the first article in a series that will chronicle the suffering within communities and explore the layered reasons behind the disparities — and what might change things.

Data show that opioid deaths reflect gaps in education, with death rates spiking in distinct age brackets and clusters appearing in specific locations. Here are a few graphs that show who is suffering.

‘The numbers only tell one side of the story’ 

If you look for data on the opioid epidemic broken down by race, you’ll find just a few categories. The Minnesota Department of Health lists Black, white, and Native American. 

The Centers for Disease Control and Prevention also lists Hispanic, Asian, and Native Hawaiian. 

Hennepin County publishes data for Black, white, Native American, Asian/Pacific Islander, and Hispanic. 

Minnesota’s largest immigrant communities — including people who are Somali, Hmong, and Karen — do not see themselves reflected in the published data. Some communities have been pleading for more transparency, believing that data is the first step to getting more support and government funding to solve the problem. 

One prominent Muslim funeral director in the Twin Cities, for example, has observed that the number of Somali overdose deaths is far higher than the reported data. In response, he believes the community should consider tracking burials of its youth.

Health leaders from state health commissioner Dr. Brooke Cunningham to President Joe Biden have also called for more specific data. National health surveys have been recording detailed racial information since 1997. But challenges with health-data collection and analysis mean that some racial categories are not broadly reported. It also means that much of what is reported likely represents an undercount.

For a variety of reasons, the death of someone whose parents were born in Somalia, for example, might be recorded as Black, Somali, or mixed race. In some cases, that recording decision may be left to the surviving family. In others, a doctor, a coroner or a medical examiner makes the call — partly depending on the county where the death occurred. It’s up to each person’s judgment to choose which box or boxes to check.

Here are the options as they appear on the standard certificate of death in Minnesota:

It’s not just matters of race and ethnicity that can be ambiguous or confusing. Causes of death may be misreported or simply marked as “undetermined.” Medical examiners typically run toxicology tests in suspected overdose cases. But under Minnesota law, family members may cite religious beliefs to seek an exemption from an autopsy. In these cases, no toxicology tests may be run and the cause of death will not be reported as an overdose.

“When I was in my addiction, almost everyone I knew used,” said Khou Vang, a peer-recovery specialist in Minneapolis who has been in recovery from drug addiction for over seven years. But the numbers don’t reflect how many people in his Southeast Asian community use substances, he said, because many don’t report addiction. People are scared that relatives might find out and a family’s reputation would be harmed, he said.

When the actual numbers of deaths are small, the mortality rates calculated with these numbers tend to be unreliable. The Minnesota Department of Health doesn’t report annual death counts within a community if the number is less than 10. However, the health department will share this information when specific communities ask for it. White Earth Nation (the Tribal community) and Alliance Wellness Center (a Somali treatment center for addiction) have participated in these reviews when the community experienced a higher-than-usual number of deaths. 

“The community might see multiple overdoses happening, and that raises concerns,”said Willie Pearl Evans, who works in overdose prevention at the state health department. 

These investigations, offered through public health officials, law enforcement, and other groups, will track an individual’s death, looking for lessons to inform future prevention efforts. 

The bottom line: The true number of people dying of overdoses — especially people of color — may be much higher than our analysis shows. The Centers for Disease Control and Prevention adds a disclaimer to its data stating, for example, that racial misclassification may underestimate death rates by as much as 34% for American Indian people.

“The numbers only tell one side of the story,” Evans said.

In small, tight-knit communities, each death has a big impact, says Dr. Antony Stately, Ph.D., executive director of the Native American Community Clinic.

“I've heard people say that way more white people have died from opioids than have Native people in terms of pure numbers,” he said. “But to lose five people in a smaller community is the equivalent sometimes of dropping an atomic bomb on that community.” 

Why are some communities more vulnerable to deaths of despair?  

Although the numbers of overdose deaths are heartbreaking to see, Minnesota experts say they’re generally not surprised. The individuals most at risk for “deaths of despair” are the same populations who fare worst in almost every health category, from prostate cancer to heart disease to maternal mortality. Minnesota’s deep racial gaps also extend beyond health, to education, income, employment and housing. 

Princeton economists coined the term “deaths of despair” in 2015 to describe the fastest rising death rates among Americans: those from drug overdoses, suicide and alcoholic liver disease. Those economists were primarily referring to white men, who accounted for the most deaths by raw numbers. 

More recent work has shown that raw numbers hide which communities are suffering most. Mayo Clinic researchers, for example, have found that in Minnesota, racial and ethnic minority populations, especially Native Americans, suffer the most deaths of despair per capita.

Smith, the University of Minnesota epidemiologist, teaches classes on disparities in drug use. Recently, researchers have been trying to solve the puzzle of why opioid overdoses have been accelerating in many Black, brown, and Native communities, she said. 

“But it’s actually been a long time coming,” she said. “Addictions reflect social inequities that have been there a long time.”

Researchers use the term “social determinants of health" to describe the conditions that people are born into, such as financial stability, access to education and exposure to neighborhood pollution. These determinants help explain the history of Minnesota’s opioid death-rate disparities. 

Dr. Dziwe Ntaba, a Twin Cities emergency physician, recently won a Bush Fellowship to support the Minneapolis Health Department’s Opioid Response Team. He said that explaining overdose inequities requires an understanding of societal stigma and bias. It also helps to understand that addiction is biological, he said, and should be treated as a disease.

Smith has tracked how opioid use has played out among Black populations on a national level. In the early 2000s, white overdose deaths climbed with the rise in legal opioid prescriptions. White Americans got more prescriptions for opioid painkillers, she said, while people in disadvantaged communities were more likely to use drugs they bought on the streets. That’s one reason the arrival of fentanyl on the streets caused Black overdoses to accelerate faster than white ones, she said. 

In addition to social determinants of health, Ntaba said, "hard-earned mistrust" of the medical community deepens divides. This mistrust goes back decades, to racist practices that treated Black patients as subjects in medical experiments. It’s the biggest barrier to people accessing treatment for addiction, Ntaba said.

“The hard-earned mistrust from Black people and Native American communities presents a barrier to seeking help or in taking a leap of faith in following medical advice,” he said.

Once people of color become addicted to opioids, Smith explained, they are less likely to access help. 

“Black Americans are now way more vulnerable to fatal opioid overdose compared to white Americans,” Smith said. 

National lawsuit settlements against prescription opioid manufacturers have yielded $75 million for Minnesota. The state reports that it has spent virtually all of that money on interventions focused on Native American, Black, and Hispanic populations.

Yet interventions have yet to reach many substance users in these communities. Those with the highest risk of overdosing are the least likely to access treatment, Ntaba said, pointing to data from the CDC. Overdose and death rates indicate these individuals are disproportionately people of color. 

The gold standard for opioid treatment involves behavior therapy and FDA-approved medications such as methadone or buprenorphine, which reduce drug cravings. Studies show they are effective in reducing opioid use and keeping patients in treatment. Many addiction experts call these medicines “miracle drugs” because they work so well. 

Doctors who specialize in addiction say this pairing is highly effective at treating substance-use disorder, lowering the risk of overdose, infectious disease, and criminal behavior. But the existence of the medications has not led to widespread access for everyone who would benefit from them.  

“Access isn't just saying, like, ‘It’s here on the shelf and the doors are open,’” Stately said. “Access includes things like ‘Can I get there? Do I have the money for it? How am I going to be treated when I show up there?’” 

Deaths are easy to measure; other damage can get lost in overdose data. “The death rate is really the canary in the coalmine in the constellation of harms,” Ntaba said.  “For every overdose death, there are thousands of unmeasured harms. Harms for the individual patients, their families, their communities and society more broadly.”

In Minnesota, each overdose death is preceded by an average of 13 emergency-room visits or hospitalizations for a non-fatal overdose, Ntaba said. And that’s not including other emergencies like serious infections or traumatic injuries.

Untreated addiction also leads to opportunistic crime, trafficking, and exploitation, he said.

Treatment is an effective solution. “Beyond saving lives, medications like buprenorphine also reduce the frequent need for E.R. visits, hospital and I.C.U. stays,” he said. “If patients are filling their prescriptions, they’re much less likely to show up in court systems, less likely to utilize social services. They move away from harm and are much more likely to reunite with families, go back to school or return to gainful employment.”  

Striving to gain a deeper understanding

If more people understood how opioids have devastated their people, according to Somali, Native American, and Southeast Asian leaders, communities could secure more funding and resources. Accurate data, they say, will convince people to pay attention and find solutions. 

Some community leaders are so eager for accurate numbers that they have attempted to keep track of overdoses themselves. 

The Muslim funeral director in the Twin Cities, for example, says the best way to tally Somali overdose deaths may be to make a note of every teen and young adult he buries. 

At the Little Earth housing community in Minneapolis, one woman tried keeping track of Native American overdoses by tallying the number of times someone uttered the word “Narcan” on the police scanner. 

White Americans are the most likely to seek treatment for drug addiction. White patients received medication for opioid use disorder (OUD) up to 80% more frequently than Black patients and up to 25% more frequently than Hispanic patients, according to a new study led by researchers at Harvard T.H. Chan School of Public Health and Dartmouth College. 

Even when patients of color do overcome barriers to access and receive prescriptions for treatment medication, mistrust continues to present challenges.

“Twin Cities patients are oftentimes prescribed doses of treatment medication that are less than half or even a third of what these patients actually need," Ntaba said.

Community leaders know where they would spend additional money: on culturally specific treatment. Such treatment includes understanding and addressing stigma and shame. 

For example, a program for mothers with addiction who live on the White Earth Reservation emphasizes Native traditions. Practitioners may offer traditional birthing practices while providing medication-assisted treatment and childcare to parents. Meanwhile, a program at HCMC connects patients who have just overdosed with peers who have recovered from addiction.

The Native American Community Clinic sends outreach teams to encampments with supplies including clothing, snacks, hygiene kits — even clean socks. 

Research shows this type of culturally responsive care — combined with medication — is the most effective at increasing access to treatment and patient retention.

For the communities of color who are suffering the most, that response can’t come soon enough. “I feel it every single day,” said Stately, the director of the community clinic — “this responsibility to try to find the answer or find a way that's going to help my community.”

This story was written by Sheila Mulrooney Eldred, who writes stories about health equity for Sahan Journal, and Cynthia Tu, the data reporter and AI specialist at Sahan Journal.

The series is part of a reporting fellowship sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund.

If you have experience with opioid addiction or recovery, Sahan Journal would love to hear from you. Email the reporters at seldred@sahanjournal.com or ctu@sahanjournal.com.