Is the Prescription Opioid Epidemic a White Problem?

Economists Anne Case and Angus Deaton report that the life expectancy of US White persons has declined,¹ largely as a result of drug overdose in the context of increased opioid analgesic use. An underacknowledged cause for this racial pattern is opioid regulation and marketing, which gave US White patients the “privilege” of unparalleled access to prescription opioids, illustrating how racially disparate drug policies and health care practices ultimately hurt White patients.

The decrease in White life expectancy began in 1998, two years after the US Food and Drug Administration approved OxyContin as a “minimally addictive” pain reliever. In the midst of the Joint Commission on Accreditation of Healthcare Organizations’ national call for pain to be monitored as a “fifth vital sign” for more adequate control, OxyContin’s manufacturer sent drug representatives to generalist physicians to promote its use for “moderate” pain conditions, with rapid uptake in primarily White states such as Maine, West Virginia, Kentucky, and Virginia.² Consumers thwarted the sustained-release capsules by crushing and dissolving them, and by 2014, deaths from opioid abuse reached an all-time high of 18 893, a 3.4-fold increase from 2001.³

At the same time, addiction neuroscience, biotechnology, federal regulation, and drug marketing each contributed to the representation of the opioid overdose epidemic as a White problem, subject to interventions distinct from those of the US War on Drugs. The resulting racialized differences between heroin and prescription opioid control resembled those created by the 1986 law distinguishing crack from powder cocaine that led the United States to the highest incarceration rates in the world, with Black and Hispanic men six and three times, respectively, as likely as White men to serve time.⁴

Through the 1990s, the US National Institute on Drug Abuse prioritized neuroscience that located addiction in the brain, supporting the idea that technologies such as sustained-release capsules could reduce addiction by preventing the reinforcing “rush” of high blood levels of opioids, while lessening attention to social context. It also made the racial patterning of opioid marketing and regulation less visible for public scrutiny.⁵ In the United States, where insurance coverage and access to physicians are racially stratified, opioid prescriptions disproportionately went to White patients, whereas non-White patients, even those with access to a physician, were less likely to be prescribed opioids, which increased racial differences in opioid use.

When nonmedical opioid use increased in White communities, rather than arresting consumers, regulators mandated physicians to use Prescription Drug Monitoring Programs, instituted voluntary take-back programs for unused medication, and disseminated the opioid overdose reversal medication naloxone, while passing Good Samaritan laws to protect those calling for emergency assistance during an overdose from drug charges. The arrest rate for sale or possession of manufactured drugs was one-quarter that for the sale or possession of heroin or cocaine,⁶ even though prescription opioid misuse far exceeded heroin use.

In addition, US Congress legalized office-based opioid maintenance with buprenorphine following expert testimony that methadone was inappropriate for the “suburban spread of narcotic addiction”; that is, middle-class opioid-dependent people were thought to be more often employed and unwilling to comply with daily observed dosing in methadone clinics that carried stigma. Three years after US Food and Drug Administration approval of buprenorphine, 91% of the US patients taking buprenorphine were White, and most were college educated, employed, and dependent on prescription opioids, in contrast to methadone patients who were less often White, college educated, or employed and who primarily used heroin.

Finally, buprenorphine marketing was demographically targeted. Manufacturer-sponsored Internet service announcements for buprenorphine featured images of White professionals (see http://www.naabt.org), and Internet-based buprenorphine prescriber matching services leveraged a computer-literate, privately insured clientele. Buprenorphine prescription requires an 8-hour certification course, and public insurance coverage for buprenorphine is variable, presenting barriers to public sector prescribers.

In the context of public concern that White Americans are turning to heroin, policymakers are calling for reduced sentencing for nonviolent illicit drug offenses and the expansion of access to addiction treatment. At the same time, in Black and Latino communities, many drug-addicted individuals continue to be incarcerated rather than treated for their addiction. Yet racially stratified responses to heroin use are ultimately harmful to all Americans, including Whites. For instance, the US opioid crisis of the 1970s that was centered in communities of color led to harsher penalties and criminalization. If we had invested in harm reduction programs and increased the availability and quality of addiction treatment then, we would have been better positioned to reduce the toll of the current opioid crisis.⁷

Public concern about White opioid deaths creates an opportunity to reorient US drug policy toward public health for all—to make proven harm reduction strategies widely available, such as naloxone for overdose reversal, and to implement interventions proven effective abroad, such as supervised injection facilities and heroin-assisted treatment, which reduce overdose deaths and improve a host of health outcomes.

Medication-assisted treatments, such as buprenorphine, methadone, and naltrexone, as well as psychosocial treatments, including motivational interviewing, cognitive and dialectical behavioral therapies, and relapse prevention, must be accessible within all communities. An array of options, many of which work optimally in combination, will enable opioid-dependent patients and their providers to tailor treatment to individual circumstances. Unless we address existing racial disparities, however, these efforts will only exacerbate inequalities. For example, expanding access to medically assisted treatment may require incentives for physicians who serve low-income patients, such as those in Federally Qualified Health Centers and in methadone clinics, to prescribe buprenorphine.

Moreover, we must rectify current and past harms of US drug policies. Decriminalizing personal possession of drugs and expunging the arrest records of thousands of mostly young men of color who have been caught up in punitive drug policies are steps in the right direction. Racial impact statements—which require legislators to evaluate if and how criminal justice reforms will affect racial disparities before voting on legislation—are another example of proactive policies that seek to address systematic racism.

Unless we scrutinize narcotics policies for their racial targeting, they reinforce inequalities in health care and law enforcement and leave White individuals, along with others, vulnerable in the face of inadequate attention to public health.