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Principle 4: Why a Focus on Racial Equity Matters

August 25, 2022

During the last 30 years of the opioid overdose crisis, over half a million lives have been lost to fatal overdoses. The latest phase of the opioid epidemic is characterized by polysubstance opioid use and dangerous synthetic opioids in the drug supply, and has increasingly affected non-white racial and ethnic groups.

Black Americans in particular have faced an alarming increase in opioid overdoses over the last decade. In 2020, the national opioid overdose death rate among Black Americans exceeded the rate for white Americans for the first time in over twenty years. Just a decade earlier in 2010, the rate of fatal opioid overdoses among white Americans was nearly three times as high as the rate for Black Americans (9.1 per 100,000 non-Hispanic white Americans versus 3.4 per 100,000 non-Hispanic Black Americans).

Many of the recent deaths among Black Americans can be attributed to fentanyl and the combined use (intentional or unintentional) of stimulants and fentanyl. Over 80% of all opioid overdoses are due to fentanyl, a powerful opioid that has contaminated much of the illicit drug supply. As explained in a recent report, black individuals who use drugs, who are also more likely to be low-income, are more likely to use street drugs and are therefore more likely to be harmed by the tainted drug supply.

In addition to differences in exposure to fentanyl, the Black population has historically experienced several challenges when accessing health programs, services, and systems. These barriers include:

  1. Lack of access to primary care and specialty providers. This population often uses emergency departments, outpatient hospitals, or urgent care clinics for their healthcare, which can make it more difficult for people to access behavioral health and substance use disorder treatment providers.
  2. Affordability of treatment. Black Americans are twice as likely to have Medicaid as white Americans, yet treatment facilities that accept Medicaid are less common in counties with high proportions of Black Americans. Moreover, a sizable proportion of treatment services, including buprenorphine, is financed through private insurance or self-pay.
  3. Experiencing discrimination that leads to mistrust of medical providers. One study showed that 79 percent of Black persons seeking substance use disorder treatment reported prior experiences being discriminated against in medical settings. Black Americans are also more than 5 times as likely to be incarcerated for possession of drugs and drug paraphernalia. This, coupled with a lack of trust in medical settings, may explain disparities in the utilization of harm reduction services.
  4. Differences in treatment quality affect the treatment options available to Black populations. One eleven-state study of Medicaid patients showed that, between 2014 and 2018, Black patients with opioid use disorder were less likely to have received any medication treatment (the gold standard) following their diagnosis than white patients.
  5. Criminalization of drug use and lack of access to treatment in carceral settings. Even though the use of drugs across racial/ethnic groups is similar, Black Americans make up a disproportionate share of individuals arrested and incarcerated for drug offenses. People who have been incarcerated are much less likely to receive treatment with MOUD following release, and are also 40 times more likely to experience an opioid overdose than someone from the general population.

The moderate increases in the treatment of opioid use disorder that has taken place over the last decade has disproportionately benefited white Americans. Specifically, the recent increase in funding and policies aimed at expanding opioid use disorder treatment across the US has been focused in areas and treatment settings that white Americans are more likely to encounter (e.g., outpatient clinics). For many of the social and economic reasons previously highlighted, as well as interpersonal discrimination by providers, treatment rates among Black Americans who use opioids remain low. Part of this may also be explained by the fact that many Black Americans are unexpectedly exposed to fentanyl while using stimulants. Since they may not classify themselves as opioid users, Black Americans could be less likely to use harm reduction services and engage in OUD treatment.

Finally, the COVID-19 pandemic has had unequal impacts on the lives of Black Americans. Black Americans have experienced far greater mortality rates per capita than white Americans, the result of persistent socioeconomic and general medical treatment disparities. The COVID-19 pandemic has also interrupted treatment services for many Americans. Although virtual services have been used to fill in these treatment gaps, they have predominantly benefited white Americans given existing disparities in access to technology.

Principle 4 of the Opioid Litigation Principles emphasizes the need to focus on racial equity when making decisions on how to spend funds from the opioid litigation. All of the Core Strategies laid out in the opioid litigation settlements and outlined in the Primer on Spending Funds from the Opioid Litigation can be used by states and localities to address racial disparities in their communities. Here are a few examples of how to focus on racial equity when implementing the Core Strategies:

Special thanks to Dr Jason Gibbons, Dr Samantha Harris, and Dr Keisha Solomon from Johns Hopkins Bloomberg School of Public Health for their assistance on this post. To learn more about this topic, listen to episode 496 of Public Health On Call Podcast on The Sharp Rise in Overdose Deaths Among Black Americans.