The opioid epidemic has garnered an increasing amount of attention from public health officials in the past two decades, but who the interventions have helped has largely depended on class and race. As a result, Black Americans are being left behind as treatment options are made more available to white communities than communities of color. And the number of Black Americans dying of opioid overdose is rising.
A U.S. Department of Health and Human Services report published in February 2020 found that Black Americans had the fastest-growing rates of synthetic opioid deaths in the country. This class of opioids, which includes fentanyl, are responsible for nearly 60 percent of all opioid deaths in the country, according to the Centers for Disease Control and Prevention (CDC).
Statistics like that show the approach to handling the opioid crisis isn’t helping everyone equitably. “We need to take a multilayer view of all of the forces that were working in concert to create the opioid crisis as we know it,” says Helena B. Hansen, MD, PhD, an associate professor of psychology at NYU Langone Health in New York City.
According to Andrew Kolodny, MD, medical director of opioid policy research at the Heller School for Social Policy and Management at Brandeis University in Waltham, Massachusetts, despite the current epidemic being painted early on as one that impacts young white Americans, there are three distinct groups suffering from the current opioid crisis.
One of those groups, he says, is disproportionately nonwhite. “That group is older, fifties and above, and more likely to reside in urban areas that were hit very hard with heroin in the 1970s and ‘80s. These people are really survivors from that epidemic,” Dr. Kolodny says. Before getting sober in 2009, Payne fell into the survivors’ group. According to Kolodny, people in this group are often the ones left without access to the treatment they need.
This is due in part to how the current epidemic was talked about. It was regularly described as being fueled by prescription pills, which predominantly impacted white communities, says Dr. Hansen. A study published in September 2018 in the journal Epidemiology found that Black Americans were prescribed prescription opioids at much lower rates than white Americans. As a result, it was less common for Black Americans to become addicted to prescription opioids.
But while prescription opioids colored the epidemic during the early aughts and kept the focus on white Americans, Hansen says that heroin and synthetic opioids, including fentanyl, are behind the rise in deaths due to opioid overdoses in recent years (a trend that’s impacted both white and Black Americans). And as it’s been since the beginning of the opioid epidemic, the response has left Black Americans behind.
White People Have Disproportionately More Access to Prescription Treatments
According to Chinazo Cunningham, MD, a professor of medicine at Montefiore Health System in the Bronx, New York, there is no cure for addiction, but most people can manage it effectively if they have access to certain medications.
“Medications are the most effective treatment and the longer people take medications, the longer they are likely to succeed in treating their condition,” she says.
However, people usually do not get the treatment they need. A study published in May 2020 in JAMA Network Open examined health insurance claim data from nearly 6,500 people who were treated in the United States for a nonfatal opioid overdose. The researchers found that very few patients received follow-up care related to addiction within 90 days of being treated for an overdose — less than 17 percent — and that Black patients were half as likely to receive follow-up treatment than white patients.
According to Pooja Lagisetty, MD, an assistant professor of internal medicine at the University of Michigan Institute for Healthcare Policy and Innovation in Ann Arbor, this is an intricate issue steeped in structural racism, but at the helm is access to medication.
Dr. Lagisetty explains that which of the two main narcotic drug addiction medications — buprenorphine or methadone — people have access to likely plays a significant role in who is more susceptible to overdose. Although both are prescriptions which are approved by the U.S. Food and Drug Administration (FDA), they are used in very different ways.
“Methadone has to be administered through a specialty addiction treatment program and patients have to show up in-person six days a week to get their supervised dose,” explains Lagisetty. In contrast, a 30-day supply of buprenorphine can be prescribed by a certified primary care physician.
“Theoretically, you can get your care in a less stigmatized environment. You can get your medication for diabetes and opioid use disorder and no one would know that you are getting treatment for addiction if that was something you were worried about,” she says, adding that attending a methadone clinic nearly every day means that daytime jobs without flexible time off and lack of transportation can easily create access barriers.
The first time she joined a methadone program, Payne had to make the daily commute to a clinic near Garfield Park on the city’s far west side, nowhere near where she was living.
Methadone made her tired, so Payne smoked crack cocaine to wake up in the morning. “The methadone would slow me down so much that I would need something to pick me up. I wanted to stop using but I just couldn't, even with the methadone. And then the methadone made me want to use other drugs,” says Payne.
As a result, her urine tests weren’t coming back clean. They upped her dose. It made her even more tired. The trip to the clinic was far, even when she switched to one 15 blocks from home. She stopped going.
“If people can get buprenorphine more easily than they can buy a bag of dope, then more people will seek treatment. But when it’s expensive, complicated, and hard to access, and you have potent and inexpensive heroin, people will continue using,” says Kolodny.
In a study published in May 2019 in the journal JAMA Psychiatry, Lagisetty and her team analyzed data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from 2004 to 2015. They found that white patients received buprenorphine prescriptions at 35 times the rate of patients who were people of color.
“Addiction has a ton of racist roots and addiction treatment is completely separate from the rest of the health system,” says Dr. Cunningham. “Methadone clinics are highly regulated and specifically located in communities of color, while buprenorphine treatment is less regulated and more white patients get it than Black patients. That is a huge contributor to these increasing rates of opioid overdoses among Black Americans.”
In addition, the 2019 study found that 34 percent of prescriptions were paid for with private insurance and 40 percent of patients who received the prescription paid out of pocket. Medicare and Medicaid, federal health insurance that covers low-income Americans, people over 65, and those with disabilities, accounted for just 19 percent of visits, despite the fact that 30 percent of all Americans are covered under this type of insurance. According to Kolodny, just 5 percent of doctors in the United States have completed the eight-hour training course required by the federal government before a physician can prescribe buprenorphine.
“Because there are so few doctors who can prescribe buprenorphine, and a lot of demand, a lot of them don’t take insurance,” says Kolodny. “Even with good insurance, patients often have to pay out of pocket and the doctors can name their price. This is where people who are upper middle class and who can pay for doctors can access treatment, unlike people who have a hard time paying.”
Payne was one of the lucky ones, at least at the beginning. “My mother would pay for me to go to treatment or live in nice halfway houses, and that would keep me out of jail,” says Payne, who says that at times going to treatment would take the place of a jail sentence. “My first time ever being in treatment was when I was 17 and still on my mom's insurance. Because we had insurance, my access was amazing. It was totally different from any treatment center I have ever been to without insurance.”
Before aging off her mother’s insurance, Payne didn’t fit with the statistics. Her parents could afford to pay out of pocket to send her to well-equipped in-patient treatment programs; insurance picked up the rest.
“As a Black American, the care you get still largely depends on your class,” says Payne. “When you don't have access to insurance, you're going to treatment facilities that aren’t kept up very well. They sometimes don't have beds. A lot of people who come from poverty live there.”
According to the U.S. Department of Health and Human Services Office of Minority Health, the average non-Hispanic white median household income in 2017 was over $15,000 more than non-Hispanic Black households. In addition, 20 percent more white American households had private health insurance than Black households.
“In general, the access to treatment is unequal, which makes it so different people are receiving different types of treatments,” says Lagisetty. According to Hansen, the access barrier starts with who drug companies had in mind when they created the medications. She says that pharmaceutical companies marketed prescription opioids to doctors in suburban areas who served predominantly white patients, and that marketing for buprenorphine followed the same trend. Lagisetty points out that buprenorphine was marketed as “safe for the stable individual.” “Which means white and suburban,” she says.
“It goes well beyond the individual racial bias of doctors, it’s drug companies as well,” says Hansen. “This is systemic racism or structural racism, not the implicit bias of individual physicians. It’s the way that those implicit associations between races and addiction got baked into the fabric of drug development.”
Looking forward, Lagisetty notes that some of the in-person restrictions for methadone recipients have changed with the COVID-19 pandemic and, in many cases, people are allowed to take more doses home, which could lead to more access in the future.
“One thing we need to do is make these treatments affordable and convenient for all individuals, especially during a pandemic where there is more unemployment,” she says.
The Lasting Impact of Mass Incarceration
According to Hansen, the disproportionate rates in which Black Americans are imprisoned is another key, and often overlooked, factor fueling rising rates of opioid deaths among Black Americans.
The United States accounts for just 5 percent of the world’s population, but houses 25 percent of the global incarcerated population, according to the Drug Policy Alliance. In addition, prosecutors are twice as likely to pursue a mandatory minimum sentence for Black Americans than for white Americans charged with the same offense, and nearly 80 percent of Americans in federal prison for drug offenses are Black or Latino, the organization reports.
Eighty percent of those incarcerated in the United States are also parents, like Payne. And Black children are more than 7 times more likely than white children to have a parent in prison, according to the Bureau of Justice Statistics. Research shows that this impacts the choices these kids go on to make as adults. A study published in August 2019 in the Journal of the American Medical Association, found that children of incarcerated parents are 6 times as likely to have substance use disorder as young adults.
According to Hansen, addiction treatment programs are largely left out of prison reform plans, which creates another dangerous cycle. She says the search for cheaper, more potent drugs, which are easier to smuggle, fueled the rise of synthetic opioids such as fentanyl, which is estimated to be 10,000 times more potent than morphine, according to the CDC. Such opioids have now flooded the market. This means that people who were imprisoned while addicted to heroin years before these synthetic opioids hit the market, and did not receive effective treatment, are now at a higher risk for overdose if they use these opioids after serving their sentence, says Hansen.
“What has happened with Black America is the meeting of two really terrible situations. One is that we have still mounting mass incarceration on drug charges in Black and Brown America, and then they are released into markets that all of the sudden have much more potent opioids,” says Hansen, noting that people with criminal records often struggle to get approved for housing or hired for jobs, blocking crucial chances they have for rebuilding a life that does not include drug use.
“Each time I got out, I would come back to the same community with little to no resources at all. Once you have a record, you are socially excluded from society — you can't get a job because of your criminal history, you can't apply for certain licenses. That is discouraging, especially if you have served your time and rehabilitated,” says Payne. “Sometimes people don't have options if they don't have a strong support system.”
Feeling she was out of options, Payne often resorted to selling drugs as means of employment.
“I would think, ‘Okay, I have to eat, so I might as well go hussle,’” she says. “I used to think that maybe I could do it in a good way. I would tell myself that I wasn’t going to use the drugs, but then I would put myself in the position where I was around people who were using.”
According to Cunningham, the federal response to the current opioid crisis, which in the beginning disproportionately impacted white Americans, is quite different to the response to the drug crises of the ‘70s and ‘80s — the time when Payne first became addicted to heroin — which mainly impacted people of color.
“Up until the last couple of years, we have talked about addiction as a criminal justice problem rather than a health problem,” she says. “It was reframed as a health issue when white Americans were affected.”
It wasn’t until she was released in 2012 that Payne moved into a halfway house away from the parts of the city that, for her, were tied to using and selling heroin.
“I was clean and I was in a different community, so I thought I had a chance of staying that way for good. I had access to mental health help, school, and so much support. I've been drug free ever since,” says Payne, who now facilitates groups at the home.
Funding Research Focused on Black Communities
In 2016, the Black American death rate from opioids in Chicago was nearly 60 percent higher than for whites, according to a report by the Chicago Urban League. According to Kathie Kane-Willis, director of policy and advocacy at the Chicago Urban League, taking a culturally sensitive approach to addiction care in Black communities is crucial, and this starts with funding research that focuses on communities of color.
According to a study published in October 2019 in the journal Science Advances, Black researchers were less likely to receive funding from the National Institutes of Health (NIH). The study also found that Black applicants were more likely to propose research topics centered around community or population-level research. Research proposals with the lowest funding rates were those which focused on health disparities and patient-focused interventions.
“If you aren’t putting Black people front and center in the research, you are missing a lot of information about this community,” says Kane-Willis, who adds that federal funding has largely focused on addiction to prescription pills, which Black Americans use at lower rates than white Americans. “Everything is centered on the white experience and if you do not go out and really look at how different populations use, you’re not going to be able to fix the problem.”
Before national stay-at-home orders due to the current COVID-19 pandemic, Chicago Urban League partnered with Chicago Recovery Alliance, a syringe provider program, to distribute and train people on how to use naloxone, an emergency nasal spray that reverses an active overdose, in areas where they knew people were using opioids. Still, the data was lacking. Kane-Willis says that when giving tools away for free, it’s difficult to track whether or not they are being used and if so, by who.
“Understanding where the naloxone goes, who uses it, and who is being trained is still needed,” says Kane-Willis, who notes that Black Americans may be less likely to seek treatment or naloxone due to fear of being profiled or set-up by the police.
As is true with many addiction resources, the program got put on hold indefinitely during the pandemic. But in June, Colette Payne had naloxone on hand.
“I got a call on June 3 from my son’s friend who told me my son wouldn't wake up,” says Payne. “I keep naloxone in my house and a kit to test what you're buying to see if it has fentanyl in it. When I got there his body was still warm. I had my kit with me but the paramedics said they already did that.”
Payne’s son, who was 28, died. An autopsy report documented fentanyl in his system, the powerful synthetic opioid Payne believes killed him.
“I buried him on June 11. I have three children who are extremely close, so that one could be missing on holidays, on birthdays, is devastating for the whole family,” says Payne, who says she believes her son’s death was a wake-up call for other relatives who use.
“He had two children who we all help care for, both 3 years old,” says Payne. “It's still hard when they ask, ‘Where's my daddy?’”