Stigma at Every Step: Mistreatment of Black Americans in the Opioid Crisis

By Nathan Bennett
Associate Editor, Vol. 26

            As the COVID-19 crisis extends into its second year in the United States, the years-long epidemic of opioid misuse continues forward—and may be worsening.^[1] The opioid crisis is popularly portrayed as a problem of white America—suburban moms hooked on prescription pills and Appalachian men laid off from factory jobs turning to painkillers. Such a portrayal is typified in this 2018 New York Times report, which documents several white West Virginians struggling with substance use disorder. ^[2] The perceived whiteness of the crisis has impacted policy responses: predominantly white policymakers—at the federal and state level—have approached the issue as a matter of public health, a sharp departure from the tough-on-crime strategy employed during the “crack epidemic” associated with Black Americans.^[3]

            The shift from criminalization to a public health response is important progress in reducing reliance on the criminal justice system and helping individuals receive the treatment they need. ^[4] At the same time, the disparate treatment cannot be ignored given the severe consequences the war on drugs has had (and continues to have) on Black and Latinx populations specifically. This blog will focus in particular on the opioid crisis’s impact on Black Americans and the unique challenges Black Americans face in confronting it.

            The perception of the opioid crisis as a white phenomenon stems from real differences in overdose rates over the last twenty years.^[5] Particularly from 2006-2014, overdoses rates among white Americans far exceeded those of the Black population.^[6] Pharmaceutical companies pushed opioids on primarily White populations, which contributed to increased reliance on the drugs as some users turned to heroin, fentanyl, and other illicit drugs when they could not access prescription opioids or when they sought a bigger high.^[7] This superficially appears to be a rare circumstance where Black Americans avoided the harms of a public health tragedy, but a closer look reveals common tropes of racism in the American health care system.^[8]

Although Black Americans have been prescribed opioids at much lower rates than whites^[9] (largely due to the racist perceptions of doctors who believe that Black people have a higher pain threshold)^[10] they have not avoided the latest—and deadliest—phase of the opioid crisis.^[11] Since 2013, synthetic opioids like fentanyl have supplanted prescription drugs as the leading cause of opioid deaths.^[12] “From 2011-2016, compared to all other populations, Black/African Americans had the highest increase in overdose death rate for opioid deaths involving synthetic opioids like fentanyl and fentanyl analogs.”^[13] From 2015-2017, Black Americans experienced the highest percentage increase in  overall opioid-involved overdose deaths.^[14]

            Despite this trend, the perception of the opioid crisis as a white phenomenon has limited public health responses that addresses the needs of Black Americans. Predominantly white lawmakers at the state and local level are not targeting services for Black communities in part because of misperceptions regarding the racial makeup of the crisis.

            Medication-assisted-treatment (MAT) is considered the gold standard for opioid use disorder and has been shown to be highly effective at combating opioid addictions. However, buprenorphine, one of the most commonly utilized forms of MAT, is not available to Black Americans like it is for whites: “‘White populations are almost 35 times as likely to have a buprenorphine-related visit than black Americans,’ says Dr. Pooja Lagisetty, an assistant professor of medicine at the University of Michigan Medical School.”^[15] Medicaid’s lower reimbursement rates, reluctance among doctors to prescribe the treatment for Black Americans, and stigma within Black communities may be contributing to this vast differential.^[16] Even in the private insurance market, Black and Hispanic Americans are far less likely to receive referrals for addiction treatment after an emergency room visit for an overdose.^[17] Broader inequities in health care access only compound this problem, and lack of trust in the medical system adds further impediments for access to MAT for Black Americans.

            Relatedly, access to naloxone, a medication that rapidly reverses overdoses, is much more limited in predominantly Black communities.^[18] Distrust among first responders—like EMTs and police officers—leads to justified concern with calling for help when someone is experiencing an overdose.^[19] Federal and state programs that aim to curb Opioid Use Disorder (OUD) do not target Black communities, and often lack the resources to meet the specific needs of many Black Americans.^[20] Furthermore, incarceration, which disproportionately impacts Black families, has dramatically increased the likelihood of addiction for children of incarcerated parents. ^[21]  Lack of addiction treatment in prisons leaves those returning from prison even more susceptible to opioid abuse.^[22] 

            Even as the opioid crisis has become an issue that attracts bipartisan attention at the federal and state level, Black Americans with OUD are viewed and treated differently. Consider this account from Erica Upshaw-Givner, a Black social worker counseling those with substance abuse disorders: “A lot of times, when you look at our [White] counterparts, they want to justify this addiction as: ‘Well, it was just pills. I was in a car accident and one thing led to another.’ But, when our people had those issues, they were still a dopehead or a dope addict and that was the label they had.”^[23] This false narrative contributes to the disparate treatment of the opioid crisis compared to previous drug crises and fuels the ongoing mistreatment of Black Americans with OUD and in need of additional investment. 

[1] Chris Sweeney, A Crisis on Top of a Crisis: COVID-19 and the Opioid Epidemic, Harvard T.H. Chan School of Public Health (Feb. 16, 2021), https://www.hsph.harvard.edu/news/features/a-crisis-on-top-of-a-crisis-covid-19-and-the-opioid-epidemic/.

[2] Campbell Robertson and Mark Trent, Despair, Love and Loss: A Journey Inside West Virginia’s Opioid Crisis, New York Times (Dec. 13, 2018), https://www.nytimes.com/interactive/2018/us/west-virginia-opioids.html.

[3] See German Lopez, When a Drug Epidemic’s Victims are White, Vox (Apr. 4, 2017), https://www.vox.com/identities/2017/4/4/15098746/opioid-heroin-epidemic-race; see also

[4] Andrew Cohen, How White Users Made Heroin a Public-Health Problem, The Atlantic (Aug. 12, 2015), https://www.theatlantic.com/politics/archive/2015/08/crack-heroin-and-race/401015/

[5] Austin Frakt and Toni Monkovic, A ‘Race Case Where Racial Bias’ Protected African-Americans, New York Times: The Upshot (Nov. 25, 2019), https://www.nytimes.com/2019/11/25/upshot/opioid-epidemic-blacks.html.

[6] Id.

[7] See Teresa A. Rummans et al, How Good Intentions Contributed to Bad Outcomes: The Opioid Crisis, 93 Mayo Clinic Proceedings 344, 344-349 (Mar. 2018).

[8] Frankt and Monkovic, supra note iv.

[9] See Mark J. Pletcher et al, Trends in Opioid Prescribing by Race/Ethnicity for Patients Seekign Care in US Emergency Departments, 299 Jama 70, 70 (Jan. 2, 2008); see also Frakt and Monkovic, supra note iv.

[10] Frakt and Mokovic, supra note iv; See Kelly M. Hoffman et al, Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs About Biological Differences Between Blacks and Whites, 113 Pnas 4296 (Apr. 4, 2016); see also Deirdre Cooper Owens, Medical Racism has Shaped U.S. Policies for Centuries, Washington Post (Feb. 12, 2021), https://www.washingtonpost.com/outlook/2021/02/12/medical-racism-has-shaped-us-policies-centuries/.

[11] Monica J. Alexander et al, Trends in Black and White Opioid Mortality in the United States, 1979–2015, 29 Epidemiology 707, 712 (Sep. 2018).  

[12] Id at 708.

[13] Nana Wilson et al, Drug and Opioid-Involved Overdose Deaths — United States, 2017–2018, 69 Morbidity and Mortality Weekly Report (Mar. 20, 2020), https://www.cdc.gov/mmwr/volumes/69/wr/mm6911a4.htm#T1_down.

[14] Kumiko M. Lippold et al, Racial/Ethnic and Age Group Differences in Opioid and Synthetic Opioid–Involved Overdose Deaths Among Adults Aged ≥18 Years in Metropolitan Areas — United States, 2015–2017, 68 Morbidity and Mortality Weekly Report (Nov. 1, 2019), https://www.cdc.gov/mmwr/volumes/68/wr/mm6843a3.htm#T1_down. 

[15] Martha Bebinger, Opioid Addiction Drug Going Mostly to Whites, Even as Black Death Rate Rises, NPR: All Things Considered (May 8, 2019, 1:46 PM), https://www.npr.org/sections/health-shots/2019/05/08/721447601/addiction-medicine-mostly-prescribed-to-whites-even-as-opioid-deaths-rose-in-bla.

[16] Id.

[17] Aubrey Whelan, Even with Private Insurance, Black Overdose Patients are Half as Likely as Whites to get Addiction Treatment, Penn Study Finds, The Philadelphia Inquirer (May 27, 2020), https://www.inquirer.com/news/racial-disparities-addiction-treatment-private-insurance-opioid-crisis-20200527.html

[18] THE OPIOID CRISIS AND THE BLACK/AFRICAN AMERICAN POPULATION: AN URGENT ISSUE (2020), https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-05-02-001_508%20Final.pdf.

[19] Id.

[20] Id.

[21] Kaitlin Sullivan, Opioid Crisis Response Leaves Black Americans Behind, Everyday Health (Nov. 9, 2020), https://www.everydayhealth.com/opioid-addiction/opioid-crisis-response-leaves-black-americans-behind/.

[22] Id.

[23] Brian Broome, Amid the Opioid Epidemic, White Means Victim, Black Means Addict, The Guardian (Apr. 28, 2018), https://www.theguardian.com/us-news/2018/apr/28/opioid-epidemic-selects-white-victim-black-addict.