Terrell Jones, 64, sees firsthand how the opioid epidemic is ravaging communities of color in New York City’s South Bronx area. Now in long-term recovery from his own years-long struggle with substance use, he serves as a program manager at the New York Harm Reduction Educators, an organization that delivers services to people with substance use disorder.
“What we’re seeing here in the South Bronx is a very high rate of overdoses,” said Jones, who described a situation where opioid use collides with a host of other problems, including homelessness and related illnesses, in a neighborhood where lifesaving care is difficult to access. The isolation forced by the COVID-19 pandemic has only made it more difficult to provide services.
What Jones observes is more common than many realize. The U.S. has grappled with opioid use disorder for decades. It was only in the late 1990s, when drug manufacturers began aggressively marketing prescription opioids — leading to a dramatic uptick in overdose deaths among whites throughout the 2000s, graduating from prescription painkillers to heroin and synthetic fentanyl — that policymakers took serious notice of this public health issue. Today, communities of color also increasingly suffer from opioid use disorder. Even as the white overdose death rate has decreased in recent years, the rate among Black, Latino, and indigenous communities has skyrocketed.
Experts on drug policy name several factors responsible for this increase. For one thing, people of color are less likely to have access to health care in general. This has only made it more difficult to access opioid medications that are standard for treating opioid use disorder. Because of racial disparities in justice involvement, they are also more likely to be incarcerated in jails and prisons, where these medications are often unavailable. A deeper-rooted problem is that communities of color often lack basic social supports like stable housing, food, and education, which makes recovery harder.
“We have medication, we have a variety of harm reduction interventions that are demonstrated by evidence to improve outcomes for people with opioid use disorder,” said Sarah Twardock, Public Health Manager at Arnold Ventures. “But, unfortunately, there are significant policy failures in the U.S., rooted in stigma, that make these services hard to access, and for communities of color, that access gap is a lot greater.”
These policy failures have spurred researchers and advocates to take bold action, both locally and at the federal level, with an aim of saving lives.
More Problems, Less Treatment
Since at least 2015, communities of color have increasingly struggled with opioid use. The overdose rate for Black Americans alone has spiked 112 percent, even as the national media continues to present it primarily as a problem for white families. “Because we were operating with that framework, it made it hard for us to see the ways that Black, Latinx, and indigenous folks were also suffering in the overdose crisis,” said Kassandra Frederique, Executive Director of the Drug Policy Alliance, an organization that advances policies to reduce the harms of both drug prohibition and drug use.
Among public health experts, there is a growing acceptance that treating opioid use disorder with medications — methadone, buprenorphine, or naltrexone — can reduce recurrent use and overdose. But even as those medications have become more widely available, major barriers to access remain for communities of color.
“If we look at who is able to get access to office-based treatment, we see such a large racial disparity in access,” said Frederique. Buprenorphine, which doctors can prescribe for take-home doses, has shown to be effective for treating opioid use disorder and reducing overdoses. But in disadvantaged Black communities, a lack of licensed practitioners limits access to the drug. Most doctors have not taken the additional training that allows them to prescribe it, and few of those who have are located in communities of color. Research shows that even when Black and Latino patients see a buprenorphine-licensed doctor, they are less likely to receive a prescription for the medication.
Jones agreed that this dynamic is at play in the South Bronx. “You don't have too many doctors who can prescribe buprenorphine,” he said. “More people would get it if there were more local doctors there to prescribe it.”
Methadone, by contrast, is more widely available in communities of color through federally-licensed treatment programs. But it is highly regulated, requiring daily visits to a clinic for 90 days to receive doses, a major obstacle for many who need treatment. Because methadone is a stronger medication than buprenorphine, it also presents a risk of overdose when not used as prescribed — a fact that has led many to misunderstand it as trading one drug for another, creating high levels of stigma about using it for treatment.
Unfortunately, there are significant policy failures in the U.S., rooted in stigma, that make these services hard to access, and for communities of color, that access gap is a lot greater.Sarah Twardock Public Health Manager at Arnold Ventures
Because drug use is criminalized, many people with opioid use disorder also become entangled in the justice system, where access to treatment is extremely challenging. “A minuscule number of jails in this country — about 5 percent — treat people with opioid use disorder with the standard of care, which is medication,” said Regina LaBelle, Program Director for the Addiction and Public Policy Initiative of the O’Neill Institute for National and Global Health Law at Georgetown University.
This is a special problem for people of color, and Black Americans in particular, who face disproportionately high rates of incarceration for drug crimes as a result of the War on Drugs. LaBelle explained that people who enter the jail or prison system are often forced to withdraw from substances “cold turkey,” without the aid of medication. If they were already on medication, the experience of withdrawal makes them less likely to take up treatment again after their release, research shows. They are also more likely to overdose.
“If you're a Black person who is incarcerated with an opioid use disorder, you're much less likely to get the standard of care,” said LaBelle.
Underwriting these problems are broader social ones. Substance use intersects with major structural disadvantages for communities of color — such as high rates of homelessness, unemployment, and racial disparities in criminal justice outcomes — that magnify the impact of the opioid crisis, said Frederique. “Folks tend to miss the social determinants of health — the access to housing, food, and employment,” she explained. “Those underlying issues create the conditions where we're navigating a ‘balloon effect’ of addiction.”
Recognizing these disparities, advocates and researchers have worked in recent years to educate policymakers and promote legislation that expands access to treatment and decriminalizes substance use.
The O’Neill Institute has been a leader in this area. The organization’s Addiction and Public Policy Initiative convenes frequent roundtables to guide state legislators on how to write laws based on the evidence, use less punitive approaches, and track the effectiveness of new policies. “There's still a lot of bias and assumptions about people with substance use disorders that policymakers have,” said LaBelle. “We work towards framing that discussion differently.”
In 2019, the O’Neill Institute issued a report outlining practices to improve services for families affected by substance use disorder. The goal is to ease bias against parents with opioid use disorder, promote the use of medication, and keep families intact — an approach known as “family-centered treatment.”
A recent webinar for policymakers discussed state legislation that models access to medication for opioid use disorder in correctional settings. The organization also promotes diversion programs, like those in King County, Washington, and Portland, Oregon, that connect people to treatment prior to arrest.
Meanwhile, DPA has focused on advancing measures to decriminalize drug use and support harm reduction. “We think that ending criminalization is a health policy,” said Frederique. “When you introduce the criminal justice system, you impede people's ability to be healthy and well.”
In January 2020, DPA released a report showing that enhanced legal penalties for fentanyl possession are predominantly charged to Black and Latino Americans, undermining recent progress in criminal justice reform. Following that, the organization led a coalition to halt a congressional resolution that would have permanently classified fentanyl as a Schedule I controlled substance alongside drugs like heroin.
DPA also advocates for decriminalization policy at the state level. In Oregon, Measure 110, a ballot initiative that passed in November, will decriminalize drug use and provide addiction treatment instead of criminal justice responses for people with opioid use disorder. Frederique said the initiative will not only save lives in communities of color; it will also save tax dollars by decreasing the costs of incarceration — all while increasing state tax revenue through legal marijuana sales, an income stream the state has committed to reinvest into addiction services.
Making It a Fiscal Issue
This is important. In the face of the Covid-19 pandemic and resulting budget shortfalls for state and local governments, many legislators are looking to cut costs, LaBelle pointed out: “If a state legislature wants to pass legislation that expands access to treatment through any of these systems, particularly the criminal justice system, they're going to have to make the argument that it's going to save money.”
While researchers and advocates push these policies and educate lawmakers, practitioners like Jones are on the front lines, speaking at town halls to demand more resources for treatment locally, and working with people on the streets to deliver services. “I hope that this starts to alleviate some of the issues that poor Black and Latino communities are facing,” said Jones.
With the right resources in place, he knows what would benefit his clients — physically, mentally, and socially. “You’re meeting people in the streets where they’re at, people who are not going to keep coming into offices,” he said. “They need more access to medication treatment, more specialized groups to address their issues — and people need a place to live.”