The United States is in the midst of an overdose crisis of tremendous proportions. Even before overdose death rates spiked sharply during the COVID-19 pandemic, the United States had twice the mortality rate of the second highest country, and 20 times the global average.1 Deaths from overdose have increased year after year—nearly uninterrupted—for the past four decades. During the pandemic, the United States crossed the grim milestone of 100 000 overdose deaths in a 12-month period.2
Although overdose deaths have increased for all racial/ethnic and socioeconomic groups, these increases have not been felt equally among all Americans. Overdose and addiction have long predominated among low-income communities,3 and during the “first wave” of the overdose crisis in the early 2000s, deaths were concentrated in low-income White communities.4
However, the racial/ethnic profile of the US overdose crisis has changed sharply.5 In 2020, the overdose death rates of Black individuals overtook those of White individuals and now exceed them by nearly 20%. American Indians/Alaska Natives now have the highest overdose mortality rates of any group—30% higher than for White individuals. Far from a “White problem,” overdose prevention is now a key racial justice issue.
In this issue of AJPH, an analysis of a national data set by Pro et al. (p. S66) considers the individual- and state-level factors that help explain racial disparities in addiction treatment. Economic and community distress—including low education, high unemployment, and housing vacancy—had the strongest negative relationship to treatment success across all racial/ethnic groups. Black and American Indian/Alaska Native patients disproportionately presented for treatment in mid- to high-distress communities. Black patients were also much more likely to experience poor treatment outcomes. In addition, patients in states that have not expanded Medicaid were less likely to experience successful treatment.
These findings urge us to consider approaches to the overdose crisis that address the underlying causes of economic and community distress, with a focus on systemic racial/ethnic inequalities.
Although overdose has been largely painted as a White problem in the popular press and academic literature in recent years—as deaths among low-income White communities garnered significant public attention—racial justice advocates have disputed this narrative.6
For example, Native communities have long experienced overdose deaths at equal or higher rates than their White counterparts, yet this has not received the same recognition.5 Furthermore, Black people who use drugs face much higher risk of arrest, imprisonment, and other drug-related harms—despite using drugs at similar rates—because of well-documented racial bias in the criminal justice system.7
However, the perception of addiction as primarily affecting White Americans has led to a softening of US drug policy.6 Minimum sentencing laws were reversed. Possession of drugs was downgraded from a felony to a misdemeanor in many cases, or even decriminalized in many cities.
People experiencing addiction were also humanized. They came to be regarded as “struggling with illness” instead of “immoral criminals,” which had been the prevailing societal view during previous waves of addiction, such as crack cocaine in the 1980s, which was represented as a Black problem.6 Even conservative politicians began to emphasize the need for medical treatment, when just a few years prior they had advocated for criminal punishment. President Trump declared the opioid epidemic a “public health emergency,” unlocking new resources for treating addiction as a medical problem.
Now that overdose mortality is becoming a racial justice issue of enormous proportions, we must ensure that this push for evidence-based policies does not falter.
We are living in an incredibly dangerous time to purchase street drugs. People seeking to buy opioids in illicit markets are now being sold illicitly manufactured fentanyls and other powerful synthetic drugs, often mixed together in powders and pressed into counterfeit prescription pills. This has led to massive day-to-day fluctuations in the potency of the drug supply that can catch even experienced users off guard. Although prescription opioids continue to garner significant public, media, and policy attention,3 a very small percentage of overdose deaths now involve them.2 Continued reductions in access to opioid prescriptions through the health care system are unlikely to curb the rising tide of overdose deaths, as illicitly manufactured fentanyls and other synthetic compounds are the key substances driving increases.
This increasing danger of using street drugs has disproportionately harmed communities of color, for various reasons. Importantly, the variable potency of street drugs has increased the lethality of recent incarceration. While someone is in jail or prison, opioid tolerance is reduced; upon release, people who use drugs are less likely to be aware of shifts in street drug composition. Furthermore, incarceration destabilizes people socially and economically8: they leave prison with reduced social supports, are disqualified from many forms of housing and employment, and have had minimal or no access to treatment for substance use disorders while incarcerated.
This is how mass incarceration, which disproportionately targets Black and Native communities,7 is supercharging the US overdose crisis. Notably, the carceral response to the illicit fentanyl crisis, including increasing penalties for fentanyl analogs, is reversing progress toward decriminalization. Similarly, the growing trend of prosecuting overdose deaths as homicides has led to long prison sentences for many people who use drugs and exchange them with their friends and family members.9 These shifts threaten to worsen racial disparities in incarceration and overdose rates.
Moving forward, the overarching drivers of overdose—including structural, social, and economic inequality—must be addressed. As Pro et al. highlight, community distress is inversely related to treatment success. Patients of color are more likely to reside in areas with poor housing, employment, and educational opportunities, which are strongly related to overdose.3 Racial segregation in housing, employment, and education, tied to disinvestments from Black and Brown neighborhoods in US cities, has fueled drug-related harms for decades.3,7 These factors are compounded by deep inequalities in the US health care system in which Black, Native, and Latinx Americans have less access to addiction treatment.10,11
Many treatment advocates call for improved access to evidence-based medications such as buprenorphine, methadone, and naloxone. Although these medications represent important strategies, they are not magic bullets. Ample evidence indicates that social-structural inequalities reduce medication effectiveness. Therefore, medications alone will not remedy substance-related harms in a context of deep inequalities. Instead, to promote better treatment outcomes, more comprehensive services are needed that address housing and economic stability.12
To effectively address racial/ethnic inequalities in overdose and treatment outcomes, overdose prevention efforts must be connected to broader racial justice movements in the United States. The criminalization of drug use drives poor outcomes for people who use drugs. Similarly, racial justice advocates seek to reduce the disproportionate policing and incarceration of communities of color, which often stem largely from drug law enforcement. Drug decriminalization is therefore a key strategy for both overdose prevention and racial justice efforts.
Overdose prevention requires what racial justice movements call for: the reallocation of public funds away from racially targeted law enforcement and toward economic development in low-income communities of color. Instead of bolstering a militarized drug-focused police force, investing in small business ownership, employment, education, and housing leads to multigenerational improvements in a wide range of health outcomes, including those related to substance use.13 This kind of economic development has also been called for by those who identify the overdose crisis in rural, deindustrialized White communities as contributing to “deaths of despair.” However, this economic development must foreground racial equity, to redress the harms of decades of racially stratified disinvestments from, and drug law enforcement in, communities of color.
As the US overdose crisis continues to evolve, robust and sustained attention to both economic development and racial justice is crucial to combat rising drug-related harms.
See also Pro et al., p.
ACKNOWLEDGMENTS
J. Friedman received support from the UCLA Medical Scientist Training Program (National Institute of General Medical Sciences training grant GM008042).
CONFLICTS OF INTEREST
The authors have no conflicts of interest to declare.
