Structural and community changes during COVID-19 and their effects on overdose precursors among rural people who use drugs: a mixed-methods analysis

Suzan M Walters, Rebecca S Bolinski, Ellen Almirol, Stacy Grundy, Scott Fletcher, John Schneider, Samuel R Friedman, Lawrence J Ouellet, Danielle C Ompad, Wiley Jenkins, Mai T Pho, Suzan M Walters, Rebecca S Bolinski, Ellen Almirol, Stacy Grundy, Scott Fletcher, John Schneider, Samuel R Friedman, Lawrence J Ouellet, Danielle C Ompad, Wiley Jenkins, Mai T Pho

Abstract

Background: Drug overdose rates in the United States have been steadily increasing, particularly in rural areas. The COVID-19 pandemic and associated mitigation strategies may have increased overdose risk for people who use drugs by impacting social, community, and structural factors.

Methods: The study included a quantitative survey focused on COVID-19 administered to 50 people who use drugs and semi-structured qualitative interviews with 17 people who use drugs, 12 of whom also participated in the quantitative survey. Descriptive statistics were run for the quantitative data. Qualitative coding was line-by-line then grouped thematically. Quantitative and qualitative data were integrated during analysis.

Results: Findings demonstrate how COVID-19 disruptions at the structural and community level affected outcomes related to mental health and drug use at the individual level. Themes that emerged from the qualitative interviews were (1) lack of employment opportunities, (2) food and housing insecurity, (3) community stigma impacting health service use, (4) mental health strains, and (5) drug market disruptions. Structural and community changes increased anxiety, depression, and loneliness on the individual level, as well as changes in drug use patterns, all of which are likely to increase overdose risk.

Conclusion: The COVID-19 pandemic, and mitigation strategies aimed at curbing infection, disrupted communities and lives of people who use drugs. These disruptions altered individual drug use and mental health outcomes, which could increase risk for overdose. We recommend addressing structural and community factors, including developing multi-level interventions, to combat overdose. Trial registration Clinicaltrails.gov: NCT04427202. Registered June 11, 2020: https://ichgcp.net/clinical-trials-registry/NCT04427202?term=pho+mai&draw=2&rank=3.

Keywords: COVID-19; Drug use; Ecosocial theory; Overdose; Rural; Social determinants of health; Social ecological model.

Conflict of interest statement

The authors have no competing interests to disclose.

© 2022. The Author(s).

References

    1. Centers for Disease Control and Prevention Vital signs: overdoses of prescription opioid pain relievers–-United States, 1999–2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487–1492.
    1. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths—United States, 2010–2015. Morb Mortal Wkly Rep. 2016;65(50 & 51):1445–1452. doi: 10.15585/mmwr.mm655051e1.
    1. O’Donnell JK, Gladden RM, Seth P. Trends in deaths involving heroin and synthetic opioids excluding methadone, and law enforcement drug product reports, by census region—United States, 2006–2015. MMWR Morb Mortal Wkly Rep. 2017;66(34):897–903. doi: 10.15585/mmwr.mm6634a2.
    1. Jones CM, Einstein EB, Compton WM. Changes in synthetic opioid involvement in drug overdose deaths in the United States, 2010–2016. JAMA. 2018;319(17):1819. doi: 10.1001/jama.2018.2844.
    1. Rouhani S, Park JN, Morales KB, Green TC, Sherman SG. Harm reduction measures employed by people using opioids with suspected fentanyl exposure in Boston, Baltimore, and Providence. Harm Reduct J. 2019 doi: 10.1186/s12954-019-0311-9.
    1. Gladden RM, O’Donnell J, Mattson CL, Seth P. Changes in opioid-involved overdose deaths by opioid type and presence of benzodiazepines, cocaine, and methamphetamine—25 States, July–December 2017 to January–June 2018. MMWR Morb Mortal Wkly Rep. 2019;68(34):737–744. doi: 10.15585/mmwr.mm6834a2.
    1. Ciccarone D. The rise of illicit fentanyls, stimulants and the fourth wave of the opioid overdose crisis. Curr Opin Psychiatry. 2021;34(4):344–350. doi: 10.1097/YCO.0000000000000717.
    1. Friedman SR, Rossi D, Braine N. Theorizing, “Big Events” as a potential risk environment for drug use, drug-related harm and HIV epidemic outbreaks. Int J Drug Policy. 2009;20(3):283–291. doi: 10.1016/j.drugpo.2008.10.006.
    1. Strathdee SA, Stachowiak JA, Todd CS, et al. Complex emergencies, HIV, and substance use: no “Big Easy” solution. Subst Use Misuse. 2006;41(10–12):1637–1651. doi: 10.1080/10826080600848116.
    1. Pouget ER, Sandoval M, Nikolopoulos GK, Friedman SR. Immediate impact of hurricane sandy on people who inject drugs in New York City. Subst Use Misuse. 2015;50(7):878–884. doi: 10.3109/10826084.2015.978675.
    1. Friedman SR, Mateu-Gelabert P, Nikolopoulos GK, et al. Big Events theory and measures may help explain emerging long-term effects of current crises. Glob Public Health. 2021 doi: 10.1080/17441692.2021.1903528.
    1. Pouget ER, Sandoval M, Nikolopoulos GK, Friedman SR. Immediate impact of hurricane sandy on people who inject drugs in New York City. Subst Use Misuse. 2015;50(7):878–884. doi: 10.3109/10826084.2015.978675.
    1. Movaghar AR, Goodarzi RR, Izadian E, Mohammadi MR, Hosseini M, Vazirian M. The impact of Bam earthquake on substance users in the first 2 weeks: a rapid assessment. J Urban Health. 2005;82(3):370–377. doi: 10.1093/jurban/jti089.
    1. Robinson WT. Impact of Hurricane Katrina on the Louisiana HIV/AIDS epidemic: a socio-ecological perspective. In: Petrucci O, ed. Natural disasters—multifaceted aspects in management and impact assessment. 2013.
    1. Moore D, Fraser S. Putting at risk what we know: reflecting on the drug-using subject in harm reduction and its political implications. Soc Sci Med. 2006;62(12):3035–3047. doi: 10.1016/j.socscimed.2005.11.067.
    1. Slavova S, Rock P, Bush HM, Quesinberry D, Walsh SL. Signal of increased opioid overdose during COVID-19 from emergency medical services data. Drug Alcohol Depend. 2020;214:108176. doi: 10.1016/j.drugalcdep.2020.108176.
    1. Friedman J, Akre S. COVID-19 and the drug overdose crisis: uncovering the deadliest months in the United States, January–July. Am J Public Health. 2020;2021:e1–e8. doi: 10.2105/ajph.2021.306256.
    1. Mason M, Welch SB, Arunkumar P, Post LA, Feinglass JM. Notes from the field: opioid overdose deaths before, during, and after an 11-week COVID-19 stay-at-home order—cook County, Illinois, January 1, 2018–October 6, 2020. MMWR Morb Mortal Wkly Rep. 2021;70(10):362–363. doi: 10.15585/mmwr.mm7010a3.
    1. Glick SN, Prohaska SM, Lakosky PA, Juarez AM, Corcorran MA, Des Jarlais DC. The impact of COVID-19 on syringe services programs in the United States. AIDS Behav. 2020;24(9):2466–2468. doi: 10.1007/s10461-020-02886-2.
    1. Roxburgh A, Jauncey M, Day C, et al. Adapting harm reduction services during COVID-19: lessons from the supervised injecting facilities in Australia. Harm Reduct J. 2021 doi: 10.1186/s12954-021-00471-x.
    1. Walters S. COVID-19 and people who use drugs—a commentary. Health Behav Policy Rev. 2020;7(5):489–497. doi: 10.14485/hbpr.7.5.11.
    1. Tringale R, Subica AM. COVID-19 innovations in medication for addiction treatment at a Skid Row syringe exchange. J Subst Abuse Treat. 2021;121:108181. doi: 10.1016/j.jsat.2020.108181.
    1. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic—United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(32):1049–1057. doi: 10.15585/mmwr.mm6932a1.
    1. Bohnert ASB, Ilgen MA, Ignacio RV, McCarthy JF, Valenstein M, Blow FC. Risk of death from accidental overdose associated with psychiatric and substance use disorders. Am J Psychiatry. 2012;169(1):64–70. doi: 10.1176/appi.ajp.2011.10101476.
    1. Vlahov D, Galea S, Ahern J, Resnick H, Kilpatrick D. Sustained increased consumption of cigarettes, alcohol, and marijuana among Manhattan residents after September 11, 2001. Am J Public Health. 2004;94(2):253–254. doi: 10.2105/ajph.94.2.253.
    1. Vlahov D, Galea S, Resnick H, et al. Increased use of cigarettes, alcohol, and marijuana among Manhattan, New York, residents after the September 11th terrorist attacks. Am J Epidemiol. 2002;155(11):988–996. doi: 10.1093/aje/155.11.988.
    1. Jenkins WD, Bolinski R, Bresett J, et al. COVID-19 during the opioid epidemic—exacerbation of stigma and vulnerabilities. J Rural Health. 2020 doi: 10.1111/jrh.12442.
    1. Schranz AJ, Barrett J, Hurt CB, Malvestutto C, Miller WC. Challenges facing a rural opioid epidemic: treatment and prevention of HIV and hepatitis C. Curr HIV/AIDS Rep. 2018;15(3):245–254. doi: 10.1007/s11904-018-0393-0.
    1. Cloud DH, Ibragimov U, Prood N, Young AM, Cooper HLF. Rural risk environments for hepatitis c among young adults in Appalachian Kentucky. Int J Drug Policy. 2019;72:47–54. doi: 10.1016/j.drugpo.2019.05.006.
    1. Ezell JM, Ompad DC, Walters S. How urban and rural built environments influence the health attitudes and behaviors of people who use drugs. Health Place. 2021;69:102578. doi: 10.1016/j.healthplace.2021.102578.
    1. Ellis K, Walters S, Friedman SR, et al. Breaching trust: a qualitative study of healthcare experiences of people who use drugs in a rural setting. Front Sociol. 2020;5:98. doi: 10.3389/fsoc.2020.593925.
    1. Ezell JM, Walters S, Friedman SR, et al. Stigmatize the use, not the user? Attitudes on opioid use, drug injection, treatment, and overdose prevention in rural communities. Soc Sci Med. 2020;268:113470. doi: 10.1016/j.socscimed.2020.113470.
    1. Krieger N. Theories for social epidemiology in the 21st century: an ecosocial perspective. Int J Epidemiol. 2001;30(4):668–677. doi: 10.1093/ije/30.4.668.
    1. Muller C, Sampson RJ, Winter AS. Environmental inequality: the social causes and consequences of lead exposure. Ann Rev Sociol. 2018;44(1):263–282. doi: 10.1146/annurev-soc-073117-041222.
    1. Krieger N. Ecosocial theory, embodied truths, and the people's health. Oxford: Oxford University Press; 2021.
    1. Frank D, Mateu-Gelabert P, Perlman DC, Walters SM, Curran L, Guarino H. “It’s like ‘liquid handcuffs”: the effects of take-home dosing policies on Methadone Maintenance Treatment (MMT) patients’ lives. Harm Reduct J. 2021 doi: 10.1186/s12954-021-00535-y.
    1. Frank D, Walters SM. “I’m Going to Stop Myself Before Someone Stops Me”: complicating narratives of volitional substance use treatment. Front Sociol. 2021 doi: 10.3389/fsoc.2021.619677.
    1. Uzwiak BA, Hudgins A, Pizzicato LN. Legacies of the war on drugs: Next of kin of persons who died of opioid overdose and harm reduction interventions in Philadelphia. Int J Drug Policy. 2021;97:103351. doi: 10.1016/j.drugpo.2021.103351.
    1. McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q. 1988;15(4):351–377. doi: 10.1177/109019818801500401.
    1. Jalali MS, Botticelli M, Hwang RC, Koh HK, McHugh RK. The opioid crisis: a contextual, social-ecological framework. Health Res Policy Syst. 2020;18(1):1–9. doi: 10.1186/s12961-019-0494-2.
    1. Jalali MS, Botticelli M, Hwang RC, Koh HK, McHugh RK. The opioid crisis: a contextual, social-ecological framework. Health Res Policy Syst. 2020 doi: 10.1186/s12961-020-00596-8.
    1. Cowan E, Khan MR, Shastry S, Edelman EJ. Conceptualizing the effects of the COVID-19 pandemic on people with opioid use disorder: an application of the social ecological model. Addict Sci Clin Pract. 2021;16(1):1–6. doi: 10.1186/s13722-020-00210-w.
    1. Fetters MD, Molina-Azorin JF. The journal of mixed methods research starts a new decade. J Mixed Methods Res. 2017;11(1):3–10. doi: 10.1177/1558689816682092.
    1. Geertz C. Thick description: toward an interpretive theory of culture. Readings in the philosophy of social science. 1994:213–231.
    1. Page JB, Singer M. Comprehending drug use: Ethnographic research at the social margins. New Brunswick: Rutgers University Press; 2010.
    1. Creswell JW, Creswell JD. Research design: qualitative, quantitative, and mixed methods approaches. Thousand Oak: Sage publications; 2017.
    1. Charmaz K. Constructing grounded theory. Sage; 2014.
    1. Heckathorn DD. Respondent-driven sampling II: deriving valid population estimates from chain-referral samples of hidden populations. Soc Probl. 2002;49(1):11–34. doi: 10.1525/sp.2002.49.1.11.
    1. Young AM, Ballard AM, Cooper HLF. Novel recruitment methods for research among young adults in rural areas who use opioids: cookouts, coupons, and community-based staff. Public Health Rep. 2020;135(6):746–755. doi: 10.1177/0033354920954796.
    1. Zahnd W, Mueller G, Garner K, Jenkins W, Steward D. Cancer in rural Illinois, 1990–2010 incidence, mortality, staging, and access to care. Springfield: Center for Clinical Research, Southern Illinois University School of Medicine; 2014.
    1. Glaser BG. The constant comparative method of qualitative analysis. Soc Probl. 1965;12(4):436–445. doi: 10.2307/798843.
    1. Orne J, Bell M. An invitation to qualitative fieldwork: a multilogical approach. Milton Park: Routledge; 2015.
    1. Saunders B, Sim J, Kingstone T, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52(4):1893–1907. doi: 10.1007/s11135-017-0574-8.
    1. Lee WK, Hayashi K, DeBeck K, et al. Association between posttraumatic stress disorder and nonfatal drug overdose. Psychol Trauma Theory Res Pract Policy. 2020;12(4):373. doi: 10.1037/tra0000511.
    1. Hembree C, Galea S, Ahern J, et al. The urban built environment and overdose mortality in New York City neighborhoods. Health Place. 2005;11(2):147–156. doi: 10.1016/j.healthplace.2004.02.005.
    1. Earnshaw VA, Smith LR, Chaudoir SR, Amico KR, Copenhaver MM. HIV stigma mechanisms and well-being among PLWH: a test of the HIV stigma framework. AIDS Behav. 2013;17(5):1785–1795. doi: 10.1007/s10461-013-0437-9.
    1. Hypodermic Syringes and Needles Act, in 720 ILCS 635, I.G. Assembly, Editor. Available at: . Accessed 1 Aug 2021.
    1. Muncan B, Jordan AE, Perlman DC, Frank D, Ompad DC, Walters SM. Acceptability and effectiveness of hepatitis C care at syringe service programs for people who inject drugs in New York City. Subst Use Misuse. 2021 doi: 10.1080/10826084.2021.1892142.
    1. Muncan B, Walters SM, Ezell J, Ompad DC. “They look at us like junkies”: influences of drug use stigma on the healthcare engagement of people who inject drugs in New York City. Harm Reduct J. 2020 doi: 10.1186/s12954-020-00399-8.
    1. Ostrach B, Buer LM, Armbruster S, Brown H, Yochym G, Zaller N. COVID-19 and rural harm reduction challenges in the us southern mountains. J Rural Health. 2021;37(1):252–255. doi: 10.1111/jrh.12499.
    1. Bluthenthal RN, Simpson K, Ceasar RC, Zhao J, Wenger L, Kral AH. Opioid withdrawal symptoms, frequency, and pain characteristics as correlates of health risk among people who inject drugs. Drug Alcohol Depend. 2020;211:107932. doi: 10.1016/j.drugalcdep.2020.107932.
    1. Hunter K, Park JN, Allen ST, et al. Safe and unsafe spaces: non-fatal overdose, arrest, and receptive syringe sharing among people who inject drugs in public and semi-public spaces in Baltimore City. Int J Drug Policy. 2018;57:25–31. doi: 10.1016/j.drugpo.2018.03.026.
    1. Krieger N. Methods for the scientific study of discrimination and health: an ecosocial approach. Am J Public Health. 2012;102(5):936–944. doi: 10.2105/ajph.2011.300544.
    1. Kolak MA, Chen Y-T, Joyce S, et al. Rural risk environments, opioid-related overdose, and infectious diseases: a multidimensional, spatial perspective. Int J Drug Policy. 2020;85:102727. doi: 10.1016/j.drugpo.2020.102727.
    1. Van Draanen J, Tsang C, Mitra S, Karamouzian M, Richardson L. Socioeconomic marginalization and opioid-related overdose: a systematic review. Drug Alcohol Depend. 2020;214:108127. doi: 10.1016/j.drugalcdep.2020.108127.
    1. Schmitz J, Kral AH, Chu D, Wenger LD, Bluthenthal RN. Food insecurity among people who inject drugs in Los Angeles and San Francisco. Public Health Nutr. 2016;19(12):2204–2212. doi: 10.1017/s1368980016000306.
    1. Ahmad NJ, Allen ST, White RH, et al. Correlates of recent nonfatal overdose among people who inject drugs in West Virginia. Harm Reduct J. 2021 doi: 10.1186/s12954-021-00470-y.
    1. Riley ED, Vittinghoff E, Koss CA, et al. Housing first: unsuppressed viral load among women living with HIV in San Francisco. AIDS Behav. 2019 doi: 10.1007/s10461-019-02601-w.
    1. Walters SM, Kral AH, Lamb S, Goldshear JL, Wenger L, Bluthenthal RN. Correlates of transactional sex and violent victimization among men who inject drugs in Los Angeles and San Francisco, California. J Urban Health. 2021 doi: 10.1007/s11524-020-00494-y.
    1. Tsemberis S, Gulcur L, Nakae M. Housing first, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Am J Public Health. 2004;94(4):651–656. doi: 10.2105/ajph.94.4.651.
    1. Doran KM, Misa EJ, Shah NR. Housing as health care: New York’s boundary-crossing experiment. Obstet Gynecol Surv. 2014;69(4):195–197. doi: 10.1097/01.ogx.0000446906.02266.3c.
    1. Green TC, Case P, Fiske H, et al. Perpetuating stigma or reducing risk? Perspectives from naloxone consumers and pharmacists on pharmacy-based naloxone in 2 states. J Am Pharm Assoc. 2017;57(2):S19–S27. doi: 10.1016/j.japh.2017.01.013.
    1. State of Illinois. Public Act 099–0480. Accessed 1 Aug 2021.
    1. Walters SM, Frank D, Van Ham B, et al. PrEP care continuum engagement among persons who inject drugs: rural and urban differences in stigma and social infrastructure. AIDS Behav. 2021 doi: 10.1007/s10461-021-03488-2.
    1. Walters SM, Rivera AV, Starbuck L, et al. Differences in awareness of pre-exposure prophylaxis and post-exposure prophylaxis among groups at-risk for HIV in New York State: New York City and Long Island, NY, 2011–2013. JAIDS J Acquir Immune Defic Syndr. 2017;75:S383–S391. doi: 10.1097/QAI.0000000000001415.
    1. Walters SM, Reilly KH, Neaigus A, Braunstein S. Awareness of pre-exposure prophylaxis (PrEP) among women who inject drugs in NYC: the importance of networks and syringe exchange programs for HIV prevention. Harm Reduct J. 2017;14(1):40. doi: 10.1186/s12954-017-0166-x.
    1. Walters SM, Coston B, Neaigus A, et al. The role of syringe exchange programs and sexual identity in awareness of pre-exposure prophylaxis (PrEP) for male persons who inject drugs. Int J Drug Policy. 2020;77:102671. doi: 10.1016/j.drugpo.2020.102671.
    1. Cid A, Daskalakis G, Grindrod K, Beazely MA. What is known about community pharmacy-based take-home naloxone programs and program interventions? A scoping review. Pharmacy. 2021;9(1):30. doi: 10.3390/pharmacy9010030.
    1. Patel MR, Foote C, Duwve J, et al. Reduction of injection-related risk behaviors after emergency implementation of a syringe services program during an HIV outbreak. JAIDS J Acquir Immune Defic Syndr. 2018;77(4):373–382. doi: 10.1097/QAI.0000000000001615.
    1. Hagan H, McGough JP, Thiede H, Hopkins S, Duchin J, Alexander ER. Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors. J Subst Abuse Treat. 2000;19(3):247–252. doi: 10.1016/S0740-5472(00)00104-5.
    1. Aspinall EJ, Nambiar D, Goldberg DJ, et al. Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. Int J Epidemiol. 2014;43(1):235–248. doi: 10.1093/ije/dyt243.
    1. Bolinski RS, Walters S, Salisbury-Afshar E, et al. The impact of the COVID-19 pandemic on drug use behaviors, fentanyl exposure, and harm reduction service support among people who use drugs in rural settings. Int J Environ Res Public Health. 2022;19(4):2230. doi: 10.3390/ijerph19042230.
    1. Young M, Stuber J, Ahern J, Galea S. Interpersonal discrimination and the health of illicit drug users. Am J Drug Alcohol Abuse. 2005;31(3):371–391. doi: 10.1081/ADA-200056772.
    1. Smith LR, Earnshaw VA, Copenhaver MM, Cunningham CO. Substance use stigma: reliability and validity of a theory-based scale for substance-using populations. Drug Alcohol Depend. 2016;162:34–43. doi: 10.1016/j.drugalcdep.2016.02.019.
    1. Weich S, Blanchard M, Prince M, Burton E, Erens B, Sproston K. Mental health and the built environment: cross-sectional survey of individual and contextual risk factors for depression. Br J Psychiatry. 2002;180(5):428–433. doi: 10.1192/bjp.180.5.428.
    1. Holland KM, Jones C, Vivolo-Kantor AM, et al. Trends in US Emergency Department visits for mental health, overdose, and violence outcomes before and during the COVID-19 pandemic. JAMA Psychiat. 2021;78(4):372. doi: 10.1001/jamapsychiatry.2020.4402.
    1. Vahratian A, Blumberg SJ, Terlizzi EP, Schiller JS. Symptoms of anxiety or depressive disorder and use of mental health care among adults during the COVID-19 pandemic—United States, August 2020–February 2021. MMWR Morb Mortal Wkly Rep. 2021;70(13):490–494. doi: 10.15585/mmwr.mm7013e2.
    1. Killgore WD, Cloonan SA, Taylor EC, Dailey NS. Mental health during the first weeks of the COVID-19 pandemic in the United States. Front Psych. 2021;12:535.
    1. Holmes EA, O'Connor RC, Perry VH, et al. Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. Lancet Psychiatry. 2020;7(6):547–560. doi: 10.1016/s2215-0366(20)30168-1.
    1. Chen JT, Krieger N. Revealing the unequal burden of COVID-19 by income, race/ethnicity, and household crowding. J Public Health Manag Pract. 2020 doi: 10.1097/phh.0000000000001263.
    1. Bassett MT, Chen JT, Krieger N. Variation in racial/ethnic disparities in COVID-19 mortality by age in the United States: a cross-sectional study. PLoS Med. 2020;17(10):e1003402. doi: 10.1371/journal.pmed.1003402.
    1. Housing Assistance Council. Race & Ethnicity in Rural America. . Accessed 1 Aug 2021. doi:10.1371/journal.pone.0116198
    1. First Nations Development Institute. Twice Invisible: Understanding Rural Native America. . Accessed 1 Aug 2021.
    1. McKnight-Eily LR, Okoro CA, Strine TW, et al. Racial and ethnic disparities in the prevalence of stress and worry, mental health conditions, and increased substance use among adults during the COVID-19 pandemic—United States, April and May 2020. MMWR Morb Mortal Wkly Rep. 2021;70(5):162–166. doi: 10.15585/mmwr.mm7005a3.
    1. Millett GA, Jones AT, Benkeser D, et al. Assessing differential impacts of COVID-19 on black communities. Ann Epidemiol. 2020;47:37–44. doi: 10.1016/j.annepidem.2020.05.003.

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