Seeing the Opioid Crisis in Color

This position paper was written as a final assignment for my first semester of Medicine and Society, a four-year anthropological program at Washington University in St. Louis.

Introduction

In the thick of the 2016 presidential primaries, Republican candidate and New Jersey governor Chris Christie goes viral for an emotional humanization of individuals addicted to opioids. “I think if you’re pro-life, that means you got to be pro-life for the whole life. Not just for the nine months they’re in the womb…The 16 year old teenage girl on the floor of the county lock up — I’m pro-life for her” (HuffPost Politics, 2015, 01:45–02:00). With more than 42,000 deaths in 2016 brought on by opioid overdoses (ASPA, 2019), his words strike a chord with millions of Americans, regardless of political affiliation. He elicits empathy for those struggling with opioid addiction by punctuating his speech with personal anecdotes — first about his mother, a middle-class white woman who “tried everything” to quit and died of lung cancer, and then about his best friend, an upper class, educated, white lawyer who overdosed on Percocet (HuffPost Politics, 2015, 00:00–01:40). At first glance, his remarks seem surprisingly progressive for a conservative Republican — that is, until he is asked about his opinions on the legalization of marijuana, a drug racialized as Black and brown despite comparable usage rates among white Americans (Murakawa, 2011).

Claiming marijuana will “poison our kids,” Christie warns against the opening of marijuana shops in Jersey suburbs — towns notorious for housing white-majority populations. “People aren’t going to scream when the first head shop opens in Newark or Paterson or Camden or Trenton…It’s OK to do this just in our city, with our urban population, but keep it away from our godforsaken suburbs,” (Christie Warns…, 2017, 00:36–01:05) As he looks out into a white-majority press room, pointing to reporters and saying, “You guys live in these suburbs,” Christie contradicts his seemingly humane and sympathetic comments from a year prior, even as studies at the time show that the legalization of marijuana can decrease a state’s opioid overdoses by 25% (Bachhuber et al., 2014). Why, then, is Christie so sympathetic towards opioids and not marijuana? The answer is simple: race.

This position paper will explore the racialization of the opioid epidemic as a ‘white issue’ and challenge the notion that white communities face the epidemic’s most detrimental effects. By first proving that the epidemic’s racialization lacks a statistical basis and attributing its image to media framing, this paper will expose the various reasons for Black Americans’ exclusion from opioid prescription. Finally, this paper will draw a direct cause-and-effect relationship between exclusionary practices and Black Americans’ increased susceptibility to opioid addiction and death, underscoring the epidemic’s increased fatality for Black Americans than white Americans. An important note to make is that this paper does not intend to play ‘oppression Olympics’ between Black and white victims of opioids; rather, it seeks to dismantle a harmful generalization made about opioids that allows for the deaths of countless people of color.

Background — How Did the Opioid Crisis Arise?

Prior to the late 20th century, chronic pain without an identifiable injury or stimulus was either ignored or discredited altogether. According to Dr. Marcia Meldrum’s “A Capsule History of Pain Management,” (2003) “those who suffered from unexplained chronic pain syndromes were often regarded as deluded or were condemned as malingerers or drug abusers.” At the time, this was more than a cultural antagonization of drug use for pain; medical schools considered outdated and faulty theories for pain, like Rene Descartes’ dualistic theory and Charles Bell’s specificity theory, to be the gold standard for pain management (Meldrum, 2003). Both theories take a cause-and-effect approach to pain, attributing the gravity of an injury to the intensity of one’s pain (Trachsel et al, 2020). Pain was necessarily a symptom of some larger stressor — be it emotional or physical — and could not exist in its own right.

By the 1960s, however, a new theory for pain had entered the mainstream — a “gate control” theory that explained reports of pain without the need for an external stimulus — and physicians began to treat pain as a condition rather than a symptom (Meldrum, 2003). In 1996, the American Pain Society (APS) deemed pain “the fif­th vital sign” and advocated the use of a number system to ‘rate’ pain levels and prescribe opioids accordingly (Mandell, 2016). However noble their efforts to address the undertreatment of persistent pain, Dr. Brian F. Mandell of the Cleveland Clinic highlights several issues with the APS’s ‘fifth vital sign’ campaign; most notably, their collaboration with opioid manufacturers to produce educational material that falsely claimed, “There is no evidence that addiction is a significant issue when persons are given opioids for pain control,” (Mandell, 2016). Several opioid companies took advantage of this endorsement, and in the same year that the APS launched its pain campaign, Purdue Pharma began to aggressively promote its new product OxyContin for “non-malignant pain,” training its sales representatives to claim that the risk of addiction was “’less than 1%’” (Van Zee, 2009).

The consequence of this marketing campaign is predictable: by 2004, OxyContin had become the most abused prescription opioid in the United States (Cicero et al., 2005), marking the first of “three distinct yet interconnected waves” said to describe the American opioid crisis (Opioid Data…2020). The second wave began in 2010, when overdoses from heroin — a Schedule I illegal substance that has the same effect as prescription opioids — increased dramatically. 2013 set off the third wave, when the synthetic opioid fentanyl — an incredibly powerful opiate-based painkiller often mixed with heroin — was introduced to the market. As a result, despite the US spending the most on healthcare per capita than any country in the world, the country’s life expectancy dropped in 2014 for the first time in two decades — and has continued to drop since (Christensen, 2019). The CDC recently reported that opioids were involved in 46,802 overdose deaths in 2018, with two out of three opioid-involved overdose deaths involving synthetic opioids (Drug Overdose…2020). The sheer volume of deaths attributed to opioid abuse has led the Trump administration to declare the epidemic a public health emergency affecting all Americans (Ending America’s Opioid Crisis, 2018), yet recent public health measures have proven to serve only one demographic: white people.

Racialization of the Opioid Epidemic

Looking closer at the opioid epidemic’s death toll, one can begin to understand why it has increasingly been racialized as an issue solely affecting white communities. 90% of first-time heroin users and subsequent regular users are white (Cicero et al., 2014), a jarring statistic at face value. Moreover, Non-Hispanic whites make up the majority of the opioid overdose death toll — of the 399,230 total opioid-related deaths that occurred from 1999 to 2017, “approximately 323,939 total deaths were attributed to White, Non-Hispanics, while 75,291 were attributed to all other ethnicities” (Drake et al., 2020). “The ‘non-medical use’ of pain relievers is almost twice as high among whites as Blacks” according to the Substance Abuse and Mental Health Services Administration (Netherland & Hansen, 2016). Moreover, during the first and second waves of the epidemic, “the [mortality] rate increased substantially in 1993–2010 [for whites], while for blacks, it remained stable during this period,” (Alexander et al., 2018). From a purely quantitative standpoint, the opioid epidemic does affect mostly white people — but it does not do so disproportionately. According to the most recent US Census data (2019), white people make up 76.3% of the US population, and proportionally will experience larger numbers of opioid abuse than other minoritized groups in America.

It becomes clear, then, that the conventional understanding of the opioid epidemic as a ‘white issue’ cannot hail from statistical evidence alone; mass media becomes crucial to establishing the modern-day misattribution of whiteness to opioid abuse. In their analysis of the media’s sympathetic framing of white opioid users, Drs. Netherland and Hansen (2016) write, “Through the 2000’s, news headlines had sounded the call of the most recent American moral panic surrounding drugs — this time, among white, suburban youth and the middle-aged white housewife next door.” Depictions of opioid users in the media were overwhelmingly white, and “the victims of the opioid epidemic [had] their stories highlighted to show they are just like anybody else,” according to Erica Heffernan (2019) in “Victims and Villains: A Comparative Analysis of the Opioid and Crack-Cocaine Epidemics.” Notably, race was rarely mentioned in these headlines, conflating the epidemic’s whiteness with all of its victims and leaving no margin in which victims of color could exist.

By consistently associating white opioid abusers with humanizing stories, the media not only shifted the public’s opinion of drug use but also the government’s opinion. Regarding the former, a 2017 public policy poll showed that 61% of the public is in favor of heroin users receiving treatment, and 72% for prescription drug abusers (Drake et al., 2020). With the latter, Heffernan (2019) highlights how, “rather than discouraging drug use through harsh penalties (as the government did during the crack crisis),” the US government directed most of its $26.7 billion-dollar 2017 National Drug Control Budget toward rehabilitation programs. The US’s sympathetic response to the opioid epidemic is inextricable from its perceived whiteness — a perception that, upon closer inspection, is resoundingly false.

Black Pain: A Presumed Oxymoron

Though pain is a natural human sensation, Khiara Bridges underscores in her book Reproducing Race (2011) how racialized biology strips Black people of their right to feel pain. “Black women are fantasized to be uncannily durable (or daft) women,” Bridges writes, pulling from medical textbooks that still falsely ascribe a higher pain tolerance to Black patients. In fact, a 2016 study found that half of the sample of white medical trainees surveyed believed that Black patients had a higher pain tolerance than white patients (Hoffman, 2016) This connotation of ‘hardness’ forced on Black people is a derivation of the same racist rhetoric used to perpetuate and justify slavery: the idea that Black people were a “primitive human type that is biologically and psychologically different from civilized man” (Bridges, 2011). In deeming Black people incapable of feeling pain, the original pain-relieving purpose of many stimulants and opioids becomes an illogical explanation for Black patients to access and use drugs, leading white doctors to discredit biology and hypothesis a moral explanation: that Black people are more likely to sell and abuse drugs.

In direct contrast to the sympathetic view of white addicts as “blameless victims of their own biology,” (Netherland & Hansen, 2016) white doctors ascribe a certain level of responsibility to Black patients for their susceptibility to addiction. This is undeniably a result of the criminalization of the crack cocaine epidemic of 1980s and 90s; though headlines by the 80s did not refer to Black victims as “cocaine-crazed Negroes” as they had in the past, news outlets used the words ‘thugs’ and ‘urban’ to concretely code the epidemic as Black (Heffernan, 2019). Moreover, in nicknaming the crack cocaine business in low-income neighborhoods “the distorted American Dream,” mass media made crack cocaine out to be a personal choice made by dealers and users rather than a larger failure of the American government, warning readers of “the individual greed, desperation, and flawed morals of low-income minority communities” (Heffernan, 2019). Interestingly, the ‘distorted American Dream’ moniker notably differs from the modern-day representation of opioid overdoses as “deaths of despair” driven by economic downturns (Ruhm, 2018). This purposeful difference in semantics implies that Black people choose crack cocaine out of greed, and white people choose opioids out of helpless desperation, deeming one race blatantly more ‘deserving’ of prescription opioids. Heffernan’s analysis (2019) of news articles from the time also found an overwhelming association of crime and immorality with cocaine-related headlines, further cementing in the public’s mind a negative cause-and-effect relationship between Black people and drugs.

As a result of these key misconceptions — that Black people are less likely to feel pain and thus more likely to sell and abuse drugs — one might assume that Black people have been spared from the detrimental effects of an opioid addiction. From a purely quantitative standpoint, this is true — according to Anjali Om in the Journal of Public Health (2018), “from 1993 to 2005, 31% of white patients received opioid prescriptions, compared to only 23% of black and 24% of Hispanic patients” even when researchers adjusted for reported pain severity. In fact, in a New York Times article entitled “A Rare Case Where Racial Biases Protected African-Americans,” authors Frakt and Monkovic (2019) claim that, from 1999 to 2017, Black Americans would have experienced 14,124 additional deaths had their rates of opioid prescription been comparable to that of white Americans. Knowing that 75% of first-time heroin users begin their addiction with prescription opioids (The Numbers Behind…2015), it is easy to jump to the conclusion that strained access to prescriptions excludes Black Americans from a place in the opioid crisis conversation. Unfortunately, this superficial interpretation of data strays far from the reality of the opioid crisis in Black communities.

Effects of the Opioid Epidemic on Black Communities

Contrary to absolute statistics seeming to overrepresent white victims in the opioid crisis, recent data has shown that, by the third wave of the opioid epidemic associated with the synthetic opioid fentanyl, Black Americans had outpaced white Americans in comparative rates of opioid overdose deaths (Furr-Holden et al., 2020). Most concerning to those studying the effects of the epidemic on communities of color is the recent and sudden nature of this surge in deaths; according to a Yale University School of Medicine study, “rates of increase in opioid deaths have been rising more steeply among Blacks (43%) than whites (22%) over the last five years,” (James & Jordan, 2018). If Black Americans are less likely to be prescribed the conventional ‘precursor’ to heroin, why are they dying at disproportionately higher rates? The answer to this question lies within the question itself: Black patients’ consistent exclusion from American healthcare.

According to the National Institute on Drug Abuse (2020), “in a recent survey of people in treatment for opioid addiction, almost all — 94 percent — said they chose to use heroin because prescription opioids were ‘far more expensive and harder to obtain.’” For Black patients, decades of being statistically more likely to be “disbelieved…and denied tests, treatments, or pain medication they thought they needed” have led studies to show much lower rates of Black confidence than white confidence in the American healthcare system (Washington, 2020). Ultimately, Black patients are faced with very few options in terms of pain relief. Coupled with America’s history of excluding Black Americans from economic success and social mobility, heroin’s comparative affordability and ease of access effectively cuts out the intermediary step of becoming addicted to prescription opioids first. By limiting their access to legal opioids, the American healthcare system makes Black Americans all the more vulnerable to heroin — and, by extension, fentanyl, a substance 25–50 times more potent than heroin (Walton, 2016).

Regardless of the reason a Black person first turns to heroin, one might assume that, once they become addicted, they would have access to the same rehabilitation programs and treatments abundantly afforded to white victims — and yet again, the reality of Black Americans’ situation starkly contrasts this logical assumption. A recent study of opioid treatment disparities showed that white drug users have “near exclusive access” to buprenorphine, one of three drugs evinced to treat opioid use disorder and reduce the chance of a fatal overdose (Lagisetty et al, 2019). In fact, Black victims more often received the exact opposite of treatment for opioid use: incarceration (Drake et al, 2020), where resources to support victims through withdrawal symptoms are scarce, and the chance of fatally overdosing upon leaving jail increases (Maryland Dept., 2014).

The root cause of the opioid epidemic’s neglect of Black victims relates directly back to its false racialization as a ‘white issue.’ The same study that exposed buprenorphine’s exclusive availability to white patients found that treatment options used to address opioid addiction are limited to communities that have access to financial resources and house fewer minorities; in fact, the proportion of buprenorphine providers that only take cash as opposed to Medicaid has remained stagnant despite the recent surge in Black deaths (Lagisetty et al, 2019). In framing the crisis as a primarily white issue, resources have gradually been tailored to white patients, stripping Black communities of the established healthcare infrastructure necessary to address a sudden increase in opioid-related deaths. Had the opioid crisis been sympathetically framed by the media earlier on as one that affected both Black and white communities, measures like faith-based rehabilitation centers, which have proven more effective for minoritized groups, and Medicaid-covered buprenorphine and naloxone (Drake et al., 2020) would have dramatically decreased the climbing Black overdose death toll.

Conclusion

As rising rates of Black opioid-related deaths have shown, the systematic exclusion of Black Americans from prescription opioids and the factually incorrect framing of opioid abuse as a disproportionately white issue have exacerbated the epidemic’s effects on Black Americans. At its core, prescription opioids were introduced to the pharmaceutical market with noble intentions: to validate chronic pain conditions that had been demoralized and undertreated for far too long. Yet when the American healthcare system predicates this validation on race, those noble intentions translate to oppression very quickly.

A superficial first listen to Governor Chris Christie’s take on opioids would lead many to believe that the US has a humane, comprehensive, and progressive approach to opioid addiction. However, this position paper has proven that, through centuries of invalidating Black pain, criminalizing Black drug use, and antagonizing Black drug users, America’s opioid response has evolved into a culturally insensitive, colorblind generalization that will continue to kill Black Americans until it admits that the epidemic is, most detrimentally, an issue of color.

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