The nation’s leading association for addiction medicine professionals issued a statement earlier this year addressing the pervasive racism in United States drug policy and treatment access.
The six-page document, titled Advancing Racial Justice in Addiction Medicine and published by the American Society of Addiction Medicine, is the first in a series. It advocates for policies that result in more equitable access to prevention, early intervention, and treatment of substance use disorder, and it urges addiction medicine professionals to examine their own implicit biases.
We wanted to define [systemic racism] and emphasize that it is a social determinant of health, said Dr. Stephen Taylor, an addiction medicine specialist from Alabama who assisted ASAM in crafting its statement. And this social determinant of health has had devastating effects on the lives and health of African Americans, indigenous peoples, and other people of color.
Taylor spoke at a recent virtual presentation hosted by the National Press Foundation for journalists participating in a fellowship on covering opioids and addiction. According to him, systemic racism is defined as a system in which public policies, institutional practices, cultural representations, and other norms interact in multiple, frequently reinforcing ways to perpetuate racial group inequality.
Since the late 1800s, a large body of research reveals a pattern of systemic racism in U.S. drug policy. To assist journalists in incorporating historical context into their stories, this article examines:
How racism became entrenched in U.S. drug policy.
– The racialization of medication maintenance treatments for opioid addiction.
And how research continues to demonstrate persistent disparities in methadone and buprenorphine prescriptions.
A BRIEF HISTORY OF SYSTEMIC RACISM IN U.S. DRUG POLICY
The origins of the war on drugs in the United States and how it led to racial disparities in drug policies and addiction treatment date back to 1875, when San Francisco passed the nation’s first anti-drug law, prohibiting opium dens. The ordinance specifically targeted Chinese immigrants.
Dr. Jessica Isom, a clinical instructor of psychiatry at Yale School of Medicine, a community psychiatrist, and a consultant for diversity, equity, inclusion, and antiracism projects, stated during a National Press Foundation virtual event that opium use by Chinese individuals in opium dens was causing problems for society, including the most valued members of society, who are white people, specifically white women.
Isom stated that to harass and denigrate a population, it is necessary to attribute unfavorable characteristics to that population. In other words, terms such as smugglers, gamblers, prostitutes, and similar terms were attributed to Chinese people, who were also viewed as morally bankrupting white people.
A few decades later, the same story occurred again, this time involving Mexican immigrants.
The Mexican Revolution of 1910 resulted in the migration of Mexicans to the Southwestern United States. According to a 1994 article in The Atlantic, some immigrants brought their traditional method of intoxication with them: marijuana. Police officers in Texas asserted that marijuana induced a craving for blood and led to violent crimes. El Paso, Texas, was the first city to ban the sale or possession of marijuana in 1914, and other states followed suit, basing their decisions on unsubstantiated accounts of crimes and violence caused by marijuana use.
Isom stated that moral panic is a very effective strategy that describes this overreaction to unfounded relationships between a racial group and the use of a substance or a social group, such as those of lower socioeconomic status, and a substance.
Simultaneously, in 1914, the U.S. Congress passed the Harrison Narcotics Tax Act, which imposed a special tax on those who produce, import, manufacture, compound, deal in, dispense, sell, distribute, or give away opium or coca leaves, their salts, derivatives, or preparations, and for other purposes. A provision of the bill prohibited physicians from prescribing opioid-based drugs. According to an explanation published by the non-profit Drug Policy Alliance, this resulted in the arrest and imprisonment of numerous physicians, the formation of underground markets for the purchase and sale of opioids and cocaine, and an increase in police enforcement.
The enforcement of the law was dominated by explicit racism directed against immigrant Asian and Hispanic/Latinx labor, Black men, and concern about women stolen into white slavery, according to the American Society of Addiction Medicine’s new policy statement, Advancing Racial Justice in Addiction Medicine. This ushered in an era in which policing was prioritized over public health.
In its policy statement, ASAM notes that systemic racism in drug policy is also apparent in the Anti-Drug Abuse Act of 1986, which established a 100-fold greater sentencing disparity between water-soluble cocaine base (crack) and powder cocaine.
According to a 2006 article by the American Civil Liberties Union, the minimum sentence for distributing five grams of crack cocaine was five years in federal prison, while the minimum sentence for distributing 500 grams of powder cocaine was the same.
Crack is less expensive than powder cocaine, and the law has led to the arrest of a disproportionate number of African-Americans relative to whites.
During the National Press Foundation’s virtual event, Dr. Helena Hansen, professor and associate director of the Center for Social Medicine and Humanities at the David Geffen School of Medicine at UCLA, provided an example of a policy that never mentions race but has a clear racial intent.
In 2010, Congress enacted the Fair Sentencing Act, which reduced the disparity in sentencing between crack cocaine and powder cocaine to 18 to 1. According to this Department of Justice memorandum, the amount of powder cocaine that triggers minimum sentences of five and ten years has not changed.
In 2018, the First Step Act was signed into law, making the Fair Sentencing Act’s sentencing reforms retroactive, but its language excluded those who were previously arrested for low-level crack cocaine offenses involving 0 to 5 grams.
The missing language led to the Supreme Court case Terry v. United States, which was brought by Tarahrick Terry, who is scheduled for release this year after serving 13 years in prison for possession of 4 grams of crack cocaine. According to Reuters, the Supreme Court heard the case in May 2021, but justices were skeptical that low-level crack cocaine offenders could benefit from the First Step Act.
George Floyd’s murder by a white Minneapolis police officer who knelt on Floyd’s neck for 9 minutes and 29 seconds is another example of the pervasive racism in portrayals of individuals with opioid addiction.
The [police officer’s] defense team has weaponized George Floyd’s drug use to portray him as a dangerous, intimidating criminal who deserved what happened to him and whose death was caused more by the fact that he was a drug user than by someone putting his knee on his neck for almost 9 and a half minutes, according to the chief medical officer of the behavioral health division at Pathway Healthcare.
Even though Blacks and whites use illicit drugs at comparable rates, more than a quarter of the nearly 1.6 million people arrested for violating drug laws in 2019 were Black, according to data from the Department of Justice. In comparison, 13.4 percent of the U.S. population consists of Blacks. According to the Drug Policy Alliance, which Isom cited in her presentation, this is due to targeted policing, surveillance, and punishment strategies.
METHADONE, BUPRENORPHINE AND DISPARITIES
As a medical student in the late 1990s, Hansen first encountered opioid addiction medication treatment that could be dispensed in doctors’ offices. She was involved in the buprenorphine clinical trials.
Hansen stated during a National Press Foundation presentation that her physician supervisors were enthusiastic about buprenorphine, which they predicted would alter the medical culture.
While methadone, another medication for the treatment of opioid dependence, was and still is dispensed at clinics and requires daily trips to these clinics, buprenorphine offered the possibility of becoming accessible at doctors’ offices.
It didn’t take long, however, for Hansen to observe stark racial and socioeconomic differences between buprenorphine and methadone patients.
Methadone and buprenorphine are both synthetic opioids that inhibit the activation of brain receptors by opioids such as heroin and morphine.
Methadone is a Schedule II controlled substance and is only available through federally regulated treatment programs due to its potential for illegal diversion and overdose risk.
In 1965, Dr. Vincent Dole and Dr. Marie Nyswander introduced the use of methadone as a treatment for heroin addiction in a pilot study involving 22 patients, which was published in JAMA.
In a subsequent 1966 study published in JAMA Internal Medicine, the authors report that the patients have lost their heroin cravings as a result of maintenance therapy. No patient has developed a heroin relapse. The majority of patients are currently employed.
Systemic racism is defined as a system in which public policies, institutional practices, cultural representations, and other norms interact in multiple, frequently reinforcing ways to perpetuate racial group inequality.
Dr. Stephen Taylor According to a 2003 review titled From Morphine Clinics to Buprenorphine: Regulating Opioid Agonist Treatment of Addiction in the United States, by Dr. Jerome Jaffe, the first director of the Special Action Office for Drug Abuse Prevention created by President Richard Nixon, and Dr. Charles OKeefe, several thousand patients were enrolled in methadone maintenance treatment programs by 1969.
Over time, as the stigma associated with addiction and methadone clinics grew, communities began to resist the establishment of clinics, relegating them to marginalized urban neighborhoods, far from other medical facilities.
Hansen stated that methadone, which previously had only a quasi-medical status, now also has a quasi-criminal status.
In the early 2000s, there was an epidemic of prescription opioid addiction. Hansen stated that the majority of newly dependent individuals on prescription painkillers were white and had middle- to upper-class incomes.
Approximately at the same time, the Drug Addiction Treatment Act of 2000 (DATA 2000) was passed, allowing physicians to treat opioid addiction with narcotic medications such as buprenorphine, thereby lifting the more than 80-year ban on opioid prescription that had been in place since the passage of the 1914 Narcotics Tax Act.
The law, however, restricted the methadone system to DEA-regulated clinics with daily patient attendance requiring direct observation.
This remarkable legislative change marked a clear shift away from the war on drugs policy and rhetoric that had dominated US drug policy for decades, write Hansen and Julie Netherland in the 2017 journal BioSocieties article White Opioids: Pharmaceutical Race and the War on Drugs That Wasn’t.
They proceed: Methadone and incarceration, which were deemed appropriate policy responses for Black and Brown addicts, were not considered viable options for White addicts. New options were required, and DATA 2000 supplied them.
Hansen stated that the manufacturers of buprenorphine successfully lobbied for it to be classified as a Schedule III drug, indicating a moderate to low potential for dependence. Methadone continues to be a Schedule II substance with a high potential for abuse.
In order to prevent the illegal use of buprenorphine, the drug’s manufacturer and the federal Substance Abuse and Mental Health Services Administration developed an eight-hour certification course that prescribers must complete.
Hansen stated that the certification has become a barrier for free clinics and clinics that serve low-income patients because these clinics do not provide time or incentives to pursue certification.
She stated that the lack of public sector prescribers and the price of buprenorphine have long kept the drug in the private sector.
Prescribers will no longer be required to complete an eight-hour training course, also known as the X-waiver, as of April 2021, per federal guidelines issued by the Biden administration.
Several national organizations, including the American Medical Association and the American Society of Addiction Medicine, hailed the guidelines as a positive step forward.
YEARS OF RESEARCH SHOW DISPARITIES
More than 400 thousand Americans receive methadone. Individuals must present themselves daily for 90 days in order to receive the treatment. They are then permitted to take home a weekly bottle. To receive a month’s worth of take-home methadone, individuals must have attended the clinic for a minimum of two years.
Imagine driving to a clinic, waiting in line for an hour to an hour and a half, and then going to work every day, seven days a week. It upends everything. During the virtual presentation hosted by the National Press Foundation, Dr. Ruth Potee, director of addiction services at Behavioral Health Network in Massachusetts, stated that addiction interferes with your ability to hold a job and care for your children.
Potee stated, “I’ll be honest, I believe a large portion of it is rooted in racism.” And if substance use disorder has a racial justice component for me, it is methadone.
A 2006 report by the federal Substance Abuse and Mental Health Services Administration revealed that 91 percent of buprenorphine patients were white, compared to 53 percent of methadone maintenance therapy patients. In addition, the report revealed that 56% of buprenorphine patients had a college degree, compared to 19% of methadone patients.
In their 2013 study, Variation in use of Buprenorphine and Methadone Treatment by Racial, Ethnic, and Income Characteristics of Residential Social Areas in New York City, published in the Journal of Behavioral Health Services and Research, Hansen and her colleagues demonstrated that the disparities persisted.
In all New York City ZIP codes, they discovered that buprenorphine treatment was concentrated in areas with the highest incomes and the highest proportion of white residents. In contrast, the geographic distribution of methadone treatment rates was inverted in low-income, ethnic minority neighborhoods.
Hansen and colleagues demonstrated the disparity once more in a 2016 study published in the journal Drug and Alcohol Dependence titled Buprenorphine and Methadone Treatment for Opioid Dependence by Income, Ethnicity, and Race of Neighborhoods in New York City.
The team compared the uptake of buprenorphine and methadone treatment in New York City neighborhoods between 2004 and 2013 by income, race, and ethnicity.
Even though rates of buprenorphine treatment had increased in all regions, its uptake was slower in areas of moderate income and mixed ethnicity. Meanwhile, methadone rates had remained stable over time.
Methadone represents the racial justice aspect of substance use disorder for me.
Doctor Ruth Pottee In 2019, nearly 15 years after the 2006 SAMHSA report, another study demonstrated the racial disparities between buprenorphine and methadone treatment.
In Buprenorphine Treatment Divide by Race/Ethnicity and Payment, published in 2019 by JAMA Psychiatry, researchers demonstrated that between 2004 and 2015, the majority of buprenorphine treatment was provided to white individuals with private insurance or the ability to self-pay. Between 2012 and 2015, 95 percent of doctor visits for buprenorphine were made by white patients, and only 19 percent of visits were covered by Medicare or Medicaid.
Medicaid does cover buprenorphine, but reimbursements are low, which discourages many from participating in the program or accepting Medicaid patients.
Treatment for Opioid Use Disorder in the Florida Medicaid Population: Using a Cascade of Care Model to Evaluate Quality, a 2020 study published in The American Journal of Drug and Alcohol Abuse, confirmed the disparities.
Researchers write that older individuals and black individuals are less likely to receive a primary diagnosis and, consequently, less likely to receive treatment for [opioid use disorder]. People who are eligible for both Medicaid and Medicare are also less likely to receive a primary diagnosis of OUD than those who are eligible for Medicaid alone.
And yet another study, Association of Racial/Ethnic Segregation With Treatment Capacity for Opioid Use Disorder in Counties in the United States, published in April 2020 in JAMA Network Open, found that between 2018 and 2019, methadone clinics were significantly more likely to be located in highly segregated Black and Hispanic/Latino counties, whereas facilities providing buprenorphine were significantly more likely to be located in highly segregated white counties.
The authors write that the disparate availability of medications for [opioid use disorder] across U.S. counties represents an additional instance of racism in the design and provision of health care services.
During the National Press Foundation-hosted virtual presentation, Dr. Pierluigi Mancini explained that in the Hispanic and Latino communities, language barriers exacerbate the problem.
Mancini, project director at the National Latino Behavioral Health Association, stated that when a person is in crisis, when they are addicted, when they have a mental health issue, or when they are suicidal, they revert to their native language. Due to a lack of linguistic proficiency, half of the foreign-born population in this country cannot access these services.
Additionally, there are cultural literacy barriers.
Mancini stated that he had a client who claimed that his addiction was the result of a curse placed on him by his ex-girlfriend. And he struggled with each step of treatment for the first few weeks, but he firmly held to this belief. Therefore, we had to address them in such a way that he would not stop treatment, but would be able to comprehend what we were trying to teach him.
National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care were developed by the federal Office of Minority Health to promote health equity in various settings.
Mancini stated that having a bilingual, bicultural clinician is the optimal solution.
In addition, there are insufficient Hispanic physicians who have completed the necessary training to prescribe buprenorphine.
Therefore, if most Hispanics seek out Hispanic doctors, especially if language is a barrier, and if there are no Hispanic doctors in the buprenorphine registry despite its recent expansion, we will not be able to use buprenorphine to treat opioid use disorder, according to Mancini.
Potee anticipated that the issue of how methadone treatment is administered would be a hot topic this year, after the pandemic reached the United States and disrupted daily access to clinics.
Potee stated that the methadone regulations were written 48 years ago and have not changed in that time. And it is one of the most efficient tools in our arsenal.
A report published in April 2021 by the Regulatory Studies Center of the George Washington University urges the federal Substance Abuse and Mental Health Services Administration (SAMHSA) to allow patients to take their methadone doses home or consume it unsupervised.
There are patients in my methadone community who have stated, “I don’t want the epidemic to end.” Potee stated, “I do not want everyone to receive the vaccine because if that occurs, my life will deteriorate because it has improved under COVID.”
Hansen added that the portrayal of individuals with substance use disorders in the media has also contributed to the disparities.
In 2016, she and Netherland published The War on Drugs That Wasn’t: Wasted Whiteness, Dirty Doctors, and Race in Media Coverage of Prescription Opioid Misuse in the journal Culture, Medicine and Psychiatry, demonstrating that Black and Latino individuals were more likely to be portrayed as criminals and drug users by the media, whereas suburbanites addicted to OxyContin were consistently portrayed as victims of over-prescription or people struggling with real or existential problems
The authors write that journalists must do a better job of recognizing the racism inherent in their coverage of the opioid epidemic and becoming more aware of implicit bias in their reporting. They can begin by ensuring that their depictions of drug users are fair and equitable across race and class.
Additional research to contemplate
Pharmaceuticals for Opioid Use Disorder Save Lives: The fifth chapter of this book, published in 2019 by the National Academies of Science, Engineering, and Medicine, provides an in-depth analysis of the barriers to the wider use of medications to treat opioid use disorder.
Substance Dependence, a Chronic Illness: This widely cited study, published in JAMA in 2000, argued that addiction should be treated similarly to other chronic diseases such as diabetes and hypertension.
An Overview of Buprenorphine Treatment for Opioid Use Disorder: The study, published in 2020 in the journal CNS Drugs, reviews the drug and discusses Naltrexone, an additional FDA-approved drug for the treatment of opioid addiction. In contrast to buprenorphine and methadone, Naltrexone requires complete opioid withdrawal from the patient. Methadone and buprenorphine continue to be the gold standard for treating opioid addiction.
Opioid Treatment Deserts: Concept development and application in an urban county in the Midwest of the United States : The study, published in PLoS One in May 2021, utilized data on opioid overdoses collected by the Columbus Fire Department in Franklin County, Ohio, between 2013 and 2017 to identify geographic areas with limited or no access to treatment and recovery services. (Visit the 2018 Pew Charitable Trusts map of methadone clinics in the United States to see disparities in the accessibility of Midwest clinics.)
Statutes, rules, and recommendations for medication-assisted treatment (MAT) opioid treatment programs: This website by the federal Substance Abuse and Mental Health Services Administration provides a list of opioid treatment regulations.
The Use of Methadone in Primary Care One Small Step for Congress, One Giant Leap for Substance Abuse Treatment: This 2018 New England Journal of Medicine commentary argues that methadone treatment should be available in primary care practices in the United States, just as it is in Great Britain, Canada, and Australia.
LIST OF SOURCES FOR THIS ARTICLE
Dr. Stephen Taylor is the chief medical officer of the behavioral health division at Pathway Healthcare, an addiction and mental health treatment center in Birmingham, Alabama, as well as the Medical Director of the National Basketball Association’s Player Assistance and Anti-Drug Program. Here is Taylor’s presentation to the National Press Foundation.
Dr. Jessica Isom is a clinical instructor of psychiatry at Yale School of Medicine, a consultant for diversity, equity, inclusion, and antiracism projects, and a community psychiatrist. Here is Isom’s presentation to the National Press Foundation.
Professor and associate director of the Center for Social Medicine and Humanities at UCLA’s David Geffen School of Medicine, Helena Hansen, Ph.D. Here is Hansen’s presentation to the National Press Foundation.
Dr. Pierluigi Mancini is the National Latino Behavioral Health Association’s project director. Here is Mancini’s presentation to the National Press Foundation.
Dr. Ruth Potee is the director of addiction services for the Massachusetts Behavioral Health Network. Here is Potee’s presentation for the National Press Foundation.
The story of how systemic racism took root in policy and addiction treatment dates back to 1800s. Here’s what history and research reveal.