Equity in the Epidemic


DURHAM, NC DATA: Although African Americans make up 40% of the population, 51% of citizens taken to the ER due to overdose are African American.

The opioid epidemic has now reached black America. Drug overdose deaths are skyrocketing among black Americans.

By German Lopez@germanrlopezgerman.lopez@vox.com  Dec 22, 2017, 2:10pm EST

There's a common narrative told about America's current opioid epidemic: It is, unlike many of the drug overdose crises of the past, predominantly a white epidemic.

The newest data from the Centers for Disease Control and Prevention, however, complicates that story.

White people still suffer a greater rate of overdose deaths, and, as a majority of the population, they still make up much more of the raw total of overdose deaths.

But over the past several years, black people have been increasingly killed by drug overdoses as well — particularly, it seems, as the opioid epidemic has become less about opioid painkillers and more about heroin and fentanyl and other potent synthetic opioids.

This chart tells the broad story, showing that drug overdose death rates have steadily increased for black Americans since 2011, when heroin and fentanyl deaths began to rapidly rise, and spiked particularly in 2016:

To put this in context: Black Americans are now dying from overdoses at around the same rate as white Americans were in 2014 — which even then was considered a public health crisis.

This increase shows that America's current opioid epidemic can no longer be framed as an exclusively white problem. While more research will be necessary to discern how such levels of overdoses reached black America, there are some hints in the data — starting with the rise of heroin and fentanyl.

As the opioid epidemic has evolved, so has its reach

A quick primer on the opioid epidemic: It began in the 1990s, when doctors became increasingly aware of the burdens of pain. Pharmaceutical companies saw an opportunity, and pushed doctors — with misleading marketing about the safety and efficacy of the drugs — to prescribe opioids to treat all sorts of pain. 

Doctors, many exhausted by dealing with difficult-to-treat pain patients, complied, in some states writing enough prescriptions to fill a bottle of pills for each resident. The drugs proliferated, landing in the hands of not just patients but also teens rummaging through their parents' medicine cabinets, other family members, friends of patients, and the black market.

Over time, this led to a rise in the use of heroin and, most recently, fentanyl. These are opioids, but they are also generally cheaper in the black market than painkillers. So they provided a less expensive, potentially more potent substitute for drug dealers and users who couldn't get their hands on painkillers.

With that in mind, we can turn to the rest of the data. (A point of caution: Opioid overdose deaths, according to a recent study by researcher Christopher Ruhm, are undercounted. So these numbers likely aren't totally accurate, but they're the best data we have right now.)

By and large, the opioid painkiller epidemic hit white Americans much harder than black Americans. While opioid painkiller overdose deaths increased for both groups over the past couple decades, they increased much more quickly for white Americans.

There's a bizarre explanation for this: Studies show that doctors have generally been more reluctant to prescribe painkillers to minorities, because doctors mistakenly believe that minority patients feel less pain or are more likely to misuse and sell the drugs. In a perverse way, this shielded minority patients from the tsunami of opioid painkiller prescriptions that got white Americans addicted to opioids and led to the initial wave of deadly overdoses.

The same, however, does not appear to be true for other kinds of opioids, for which doctors aren't the gatekeepers. When it comes to heroin, fentanyl, and other non-methadone synthetic opioids, overdose death rates have climbed dramatically — particularly in 2016 — for both white and black Americans. White Americans still suffer higher rates overall, but the discrepancy between both groups isn't nearly as large as it is for painkillers.

One possible explanation: As opioid painkiller misuse went up, drug traffickers saw an opportunity for an expanded opioid market. So they flooded the US with heroin and illicit fentanyl. This made these illegal drugs much more accessible, giving more people the opportunity to use these drugs even if they weren't addicted to painkillers before. (Indeed, a recent study found that, while most people in addiction treatment for opioids got started on painkillers in 2015, an increasing amount were starting on heroin.)

This seemed to expose black people to opioids in a way they weren't exposed before. Drug dealers, perhaps, aren't as racially prejudiced as doctors in whom they provide drugs to — so they've let the expansion in the supply of heroin and fentanyl reach black people.

Another possibility is that the black Americans who have long been addicted to heroin, perhaps due to the previous heroin epidemic in the 1970s, have started to die to overdoses at greater rates as the heroin supply during the current crisis has become increasingly contaminated with the more potent and dangerous fentanyl. This may explain why the highest rates of black overdose deaths in 2016 were among 55- to 64-year-olds, although the overdose death rates among younger groups were still fairly high and accelerating.

"Despite beating the odds for the past 40 to 50 years," Andrew Kolodny, an opioid policy expert at Brandeis University, told the New York Times, "they're dying because the heroin supply has never been so dangerous — increasingly it's got fentanyl in it or it's just fentanyl sold as heroin."

There's also been an overall rise in cocaine overdose deaths in the past few years, from 1.6 per 100,000 people in 2013 to 3.2 per 100,000 people in 2016. One possibility is that people are mixing opioids and cocaine, which increases the odds of overdose for both drugs. Whatever the reason, this disproportionately hits black Americans, who are generally more likely to die from cocaine overdoses.

Still, opioids are now linked to more overdose deaths than cocaine even among black Americans: While the cocaine overdose death rate for black people was 5.9 per 100,000 in 2016, the opioid overdose death rate among black people was 10 per 100,000.

Since they are a smaller portion of the general population, black people still make up much less of the raw total of overdose deaths than white people. So in the raw figures, white deaths vastly surpass black deaths: In 2016, nearly 55,000 white people in the US died of all drug overdoses, while more than 7,000 black people did. 

Of course, that doesn't make the rise in black overdose death rates any less unsettling, given that they still show an increasing share of the population is being killed by the current overdose crisis.

America needs greater access to treatment everywhere

The opioid epidemic's reach into black communities creates new challenges. A critical solution to the opioid crisis is improved access to addiction care, which in large part necessitates better access to health care. But black Americans have long had worse access to health care than their white peers. The uninsured rate for nonelderly black Americans is 12 percent, while it's 8 percent for nonelderly white Americans, according to the Kaiser Family Foundation.

The same trend appears to hold for addiction care. Treatment rates are generally low in the US — about 10 percent of people with a substance use disorder get specialty treatment, according to a 2016 report from the surgeon general. But the White House opioid commission found that black people with opioid use disorders were among several groups, including adolescents and the uninsured, who especially "underutilized opioid-specific treatment."

Of course, history shows that when black Americans are hit by a drug crisis, lawmakers tend to react with a focus on punitive criminal justice policies — even though such an approach is largely ineffective, according to the empirical evidence, and even though experts say that a major element to addressing the opioid crisis, as well as other drug overdose epidemics, is dramatically expanding access to addiction treatment.

All of this shows the need for a universal expansion of addiction treatment. It's not enough to simply boost treatment among currently afflicted areas or populations. Given that drug crises can expand and pop up in unexpected places, it's better to take preventive steps that ensure everyone will have access to addiction care if they ever need it — just as people should have access to other kinds of health care in case they suddenly suffer from, say, heart disease, diabetes, or cancer. 

Simply put: Addiction treatment needs to be integrated into our medical system just like any other health care service.


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