Gain insight into how racialized US drug policies, the War on Drugs, and media portrayals of substance use impact our patients in ongoing ways. Learn how you can take action and intentionally promote equity as a clinician! We’re joined by Dr Myra Mathis, @DrMyraMathis (University of Rochester Medical Center)
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Black, Indigenous, and People of Color. This term centers the specific discrimination that Black and Indigenous people face.
Race is a social construct that assigns value and importance to individuals by the color of their skin. It has no biological or genetic underpinning.
Race leads to the system of racism that creates a structural hierarchy, where lighter skin has been valued as better or more important than darker skin. Based on this hierarchy, some individuals receive privileges and others are disadvantaged. The system of racism permeates other systems in society such as housing policies, generational wealth, education, and healthcare.
The War on Drugs was officially declared by President Richard Nixon in 1971. It created an enforcement infrastructure that expanded policing systems, primarily based in communities experiencing poverty. BIPOC individuals are overrepresented in these communities due to systemic racism, so have been impacted more than others by these policies. Black and Latinx individuals use drugs at similar rates as White individuals (SAMHSA 2021), but stigma and the War on Drugs created legal disparities as mass incarceration accelerated.
This law established federal mandatory minimum sentences of five years for possession of five grams of freebase (crack) cocaine and 500 grams of powder cocaine, even though freebase (crack) cocaine and powder cocaine are different formulations of the same compound (Hatsukami 1996). This 100:1 disparity in sentencing disproportionately impacted BIPOC communities in urban areas (Goulian 2022, Palamar 2015).
The Fair Sentencing Act in 2010 reduced penalties for crack cocaine offenses (United States Sentencing Commission 2015), and legislation has since been proposed to further reduce the disparity (White House 2023). However, these efforts began after thousands were sentenced and lost many years to imprisonment under the initial law. It is important to keep this history in mind as new laws target fentanyl use and distribution (Ray 2023). We should consider who we view as needing treatment and protection versus criminalization.
Despite some positive changes at the federal level, the majority of individuals are incarcerated in state prisons, so these changes are not happening uniformly across the country.
The use of person-first and non-stigmatizing language matters in the media because it impacts public perception (McGinty 2015; NIH 2021). Stigmatizing or demonizing language has historically been used to portray BIPOC individuals, in particular Black men with substance use disorders, and particularly with the use of freebase cocaine (Shachar 2020). Portrayals intended to provoke fear justified the laws that created the 100:1 sentencing disparity (Netherland 2016). These portrayals have softened with the opioid crisis as it has become increasingly associated with White people. Portrayals have started to focus on the lives that people lead outside of substance use instead of treating substance use as a person’s defining characteristic.
Substance use disorders in BIPOC individuals tend to reflect other medical conditions in one key way; they present later and with more severe courses of illness than they would in individuals who have not been marginalized out of treatment (Matsuzuka 2020). The compounded stigma of substance use disorders and racism can further deter people from presenting for care (Hammarlund 2018). When BIPOC individuals do present for care, they are less likely than white individuals to receive medication for OUD (Barnett 2023). This disparity persists despite the fact that rates of overdose deaths among BIPOC individuals is outpacing these rates for white individuals (Larochelle 2021). Whiteness operates as a form of privilege that confers compassionate media portrayals and greater access to treatment (Faiz 2022).
Clinicians can advocate to apply a racial justice lens to the distribution of funds at the policy level, for instance for states receiving opioid settlement funds from pharmaceutical company lawsuits (National Academy for State Health Policy 2022). On the clinical level, we can take a structural competency approach to support our patients’ engagement in care and address social determinants of health (Jackson 2022). Harm reduction is a helpful framework here (Kapadia 2021) – how can we make a plan that feels safe and workable for patients, regardless of whether they actively use substances? Using an open, non-judgemental approach is critical to engage communities that have been stigmatized and racially discriminated against, who may expect to be dismissed in healthcare settings.
Methadone and buprenorphine are both extremely effective for the treatment of OUD, but differences in how the two are regulated are not data-driven. Rather, opioid treatment programs, or methadone clinics, were established in parallel with the expansion of law enforcement heightening policing directed toward BIPOC communities (Netherland 2017). These carceral ideas leaked into the structure of these clinics. As a result, methadone is the most tightly regulated medication in the US. Individuals with wealth have pushed back against local placement of these clinics, so the clinics are more often located in neighborhoods impacted by poverty with divestment of other resources. Individuals who are Black or Latinx are more likely to be prescribed methadone than buprenorphine (Goedel 2020). Methadone is as effective as buprenorphine but comes with fewer flexibilities for take-home doses, so individuals remain confined to certain locations.
By the time buprenorphine was approved, the demographics of heroin use had shifted (Cicero 2014) and the perception of opioid use disorder had shifted to be a white, rural or suburban problem. Suddenly people could attend a primary care appointment and leave with a 30-day script for buprenorphine to be dispensed at a pharmacy, without having to worry about a daily trip to a specialized clinic. Today, buprenorphine is prescribed at higher rates for white individuals than it is for BIPOC individuals (Lagisetty 2019).
SAMHSA did increase flexibilities for methadone during the COVID pandemic, and legislation to liberalize methadone prescribing has been introduced (SAMHSA 2023).
The US has a system of assigned preferential hierarchies based on race. The concept of race neutrality implies a preference for the maintenance of current systems, rather than restructuring to promote equity and balance. Antiracism requires action and intentionality. For instance, clinicians can identify disparities in our own prescribing practices through audits of our own patient panels. Cultural humility involves the recognition that we don’t know what it’s like to live as our patients and need to follow their leads, while simultaneously evaluating our own cultures and beliefs through self-critique. This framework can serve as a helpful tool.
The US has a sad and painful history as it relates to race and racism, and this is particularly salient in addiction medicine due to the War on Drugs and racialized drug policy. We must ask ourselves how our clinical decisions impact our most marginalized patients. If you don’t know how your decisions are impacting your patients, make a point to listen to and learn from them. Take note of who you are inviting in – who has access to your services (Rosales 2022)? What kinds of families does the signage in your clinic portray? To what extent are new organizational policies utilizing a racial health equity lens (Jordan 2021)?
Listeners will explore how the War on Drugs and racist media portrayals in the United States have created inequities in the ways that drug use is treated or criminalized.
After listening to this episode listeners will…
Dr. Mathis reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Mullins K, Mathis ML, Sonoda K, Chan CA. “Racism and Inequities in Addiction Medicine”. The Curbsiders Addiction Medicine Podcast. https://thecurbsiders.com/addiction September 7th, 2023.
Producer, Writer, Show notes, Infographic, Cover Art: Katherine Mullins, MD
Hosts: Carolyn Chan, MD, MHS and Katherine Mullins, MD
Reviewer: Kento Sonoda, MD
Showrunner: Carolyn Chan, MD, MHS
Technical Production: PodPaste
Guest: Myra Mathis, MD
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