Expert Commentary

Racial disparities in opioid addiction treatment: a primer and research roundup

The story of how systemic racism took root in policy and addiction treatment dates back to the 1800s. Disparities persist today in the prescription of methadone and buprenorphine. Here's what history and research reveal.

Image by Jessica Hatchell from Pixabay

Earlier this year, the nation’s leading association for addiction medicine professional issued a statement addressing the systemic racism that pervades the United States’ drug policy and access to treatment. 

The six-page document, issued by the American Society of Addiction Medicine and titled “Advancing Racial Justice in Addiction Medicine,” is the first in a series. It recommends a more diverse addiction treatment workforce; advocates for policies that result in more equitable access to prevention, early intervention and treatment of substance use disorder; and it calls on addiction medicine professionals to examine their one biases. 

“We wanted to define [systemic racism] and we wanted to point out that systemic racism is a social determinant of health,” said Dr. Stephen Taylor, an Alabama-based addiction medicine specialist who helped ASAM craft its statement. “And that social determinant of health has had profound deleterious effects on the lives and health of Black, Indigenous and other people of color.”

Taylor spoke during a recent virtual presentation hosted by the National Press Foundation, for an audience of journalists participating in a fellowship on covering opioids and addiction. He said systemic racism is “defined as a system in which public policies, institutional practices, cultural representations and other norms work in various, often reinforcing, ways to perpetuate racial group inequity.”

 A large body of research reveals a long pattern of systemic racism in U.S. drug policy dating back to the late 1800s. To help journalists add historical context to their stories, this piece delves into:

  • How racism took root in U.S. drug policy.
  • How medication maintenance treatments for opioid addiction became racialized.
  • And how research continues to show persisting disparities in the prescription of methadone and buprenorphine.

A brief history of systemic racism in U.S. drug policy

The story of how the war on drugs started in the United States and how it led to racial disparities in drug policies and addiction treatment dates back 1875, when San Francisco passed the nation’s first anti-drug law, the Opium Den Ordinance, banning opium dens. Specifically, the ordinance was directed at Chinese immigrants. 

“So what they created was this story that the use of opium by Chinese persons in opium dens was causing problems for society, including the people most valued in society, which are white people, specifically white women,” said Dr. Jessica Isom, a clinical instructor of psychiatry at Yale School of Medicine, a community psychiatrist and consultant for diversity, equity, inclusion and antiracism projects, during the National Press Foundation’s virtual event.

In other words, “to harass and denigrate a population, it requires that you assign characteristics to that population that are unfavorable,” said Isom. “What that means is that language such as “smugglers”, “gamblers”, “prostitutes”, and things of that nature, were ascribed to Chinese people, and they were also considered to be morally bankrupting white people.”

A few decades later, the story repeated itself, but this time for Mexican immigrants. 

The Mexican Revolution of 1910 led to immigration of Mexicans to the U.S. Southwest. Some of the immigrants brought with them their traditional means of intoxication: marijuana, according to a 1994 article in The Atlantic. Texas police officers claimed that marijuana aroused a “lust for blood” and led to violent crimes. El Paso, Texas, was the first city banning the sale or possession of marijuana in 1914 and other states followed, basing their decision on unfounded narratives of crimes and violence resulting from smoking marijuana. 

“One term that describes all of this, this overreaction to what really are unfounded relationships between a racial group and use of a substance — or some kind of social group, could be those who are considered lower socioeconomic status and a substance — is “moral panic”, and it’s a very effective strategy,” said Isom. 

Around the same time, in 1914, the Harrison Narcotics Tax Act was passed by the U.S. Congress, imposing “a special tax upon all persons who produce, import, manufacture, compound, deal in, dispense, sell, distribute, or give away opium or coca leaves, their salts, derivatives, or preparations, and for other purposes.” One clause in the bill also banned doctors from prescribing drugs that were opioid based. This led to the arrest and imprisonment of many doctors, formation of underground markets to buy and sell opioids and cocaine and increased police enforcement, according to an explainer by the nonprofit Drug Policy Alliance.

The enforcement of the law was dominated by “explicit racism directed against immigrant Asian and Hispanic/Latinx labor, Black men and concern about women stolen into “white slavery” – and it ushered in a period that prioritized policing over public health,” according to ASAM’s new policy statement, “Advancing Racial Justice in Addiction Medicine”. 

ASAM’s policy statement points out that systemic racism in drug policy is also recognizable in the Anti-Drug Abuse Act of 1986, “which enacted a 100-fold greater sentencing disparity for water-soluble cocaine base (“crack”) versus powder cocaine.”

For instance, distribution of five grams of crack carried a minimum of five-year sentence in federal prison, while distributing 500 grams of powder cocaine has the same sentencing, according to a 2006 article by American Civil Liberties Union.

Crack is cheaper than powder cocaine and over time the law resulted in the arrest of disproportionate number of Black individuals compared with whites.

“That’s one example of a policy where race is never mentioned, but there’s a clear racial intent,” said Dr. Helena Hansen, professor and associate director of Center for Social Medicine and Humanities at David Geffen School of Medicine at UCLA, during the National Press Foundation’s virtual event.

In 2010, the Congress passed the Fair Sentencing Act, reducing the sentencing disparity between crack and powder cocaine to 18 to 1. The amount of powder cocaine triggering minimum sentencing of five and 10 years remained the same, as explained in this Department of Justice memo.

In 2018, the First Step Act was signed into law, making sentencing reforms of Fair Sentencing Act retroactive, but its language left out those who were previously arrested for low-level offenses that involved 0 to 5 grams of crack cocaine.

The missing language led to Supreme Court case Terry v. United States, brought on by Tarahrick Terry who’s scheduled to be released from prison this year after 13 years for possession of 4 grams of crack cocaine. In May 2021, the Supreme Court heard the case but justices were skeptical that low-level crack cocaine offenders can benefit from the First Step Act, Reuters reported.

Another reminder of pervasive racism in portrayal of individuals with opioid addiction was George Floyd’s murder by a white Minneapolis police officer, who knelt on Floyd’s neck for 9 minutes and 29 seconds. 

“George Floyd’s drug use has been used by the [police officer’s] defense team to basically try to weaponize it against him, to make him seem like a dangerous, imposing criminal, who basically deserved what happened to him and whose death was caused more by the fact that he was a drug user than because of someone putting his knee on his neck for almost 9 and 1/2 minutes,” said Taylor, chief medical officer of behavioral health division at Pathway Healthcare, an addiction and mental health treatment center in Birmingham, Alabama, and medical director of the Player Assistance and Anti-Drug Program at the National Basketball Association. 

Even though Black and white people use illicit drugs at a similar rate, Black people made up more than a quarter of nearly 1.6 million people arrested for violation of drug laws in 2019, according to the Department of Justice data. In comparison, the Black population makes up 13.4% of the U.S. population. This is due to “targeted policing, surveillance, and punishment tactics,” according to the Drug Policy Alliance, which Isom cited in her presentation. 

Methadone, buprenorphine and disparities

Hansen first encountered opioid addiction medication treatment that could be dispensed in doctors’ offices in the late 1990s when she was a medical student. She was involved with the clinical trials of buprenorphine.

Her physician supervisors were excited about buprenorphine, which “they said was about to change the culture of medicine,” said Hansen, during the National Press Foundation presentation.

While methadone, another medication for treatment of opioid dependence, was, and is still, dispensed at clinics and requires daily trips to those clinics, buprenorphine came with the promise of becoming available at doctors’ offices. 

But as promising as that was, it didn’t take long for Hansen to begin noticing stark differences between buprenorphine and methadone patients by race and class. 

Methadone and buprenorphine are synthetic opioids and they act similarly by blocking the brain receptors that are activated by opioids such as heroin and morphine.

Methadone is a Schedule II controlled substance and can only be dispensed at federally-regulated treatment programs, a restriction that resulted from its potential to be diverted to the streets for illegal use and the possibility of overdose. 

The use of methadone as a treatment for heroin addiction was first introduced in a pilot study of 22 patients by Dr. Vincent Dole and Dr. Marie Nyswander, published in JAMA in 1965. 

“With the maintenance treatment, the patients have lost their craving for heroin,” the authors write in a subsequent 1966 study published in JAMA Internal Medicine. “No patient has become readdicted to heroin. A majority of the patients are now steadily employed.” 

“Systemic racism has been defined as a system in which public policies, institutional practices, cultural representations and other norms work in various, often reinforcing, ways to perpetuate racial group inequity.”

Dr. Stephen Taylor

By 1969, several thousand patients across the United States were enrolled in methadone maintenance treatment programs, according to a 2003 review, “From Morphine Clinics to Buprenorphine: Regulating Opioid Agonist Treatment of Addiction in the United States,” co-authored by Dr. Jerome Jaffe, the first director of the Special Action Office for Drug Abuse Prevention created by President Richard Nixon, and Dr. Charles O’Keefe. 

Over time, because of the growing stigma associated with addiction and methadone clinics, communities began resisting the establishment of clinics, pushing the clinics to marginalized neighborhoods in the cities, remote from other medical services. 

“So methadone, [which has] had this only quasi-medical status, also [gets] a quasi-criminalized status in that sense,” Hansen said. 

Fast forward to the early 2000s and the prescription opioid addiction epidemic. Most of the newly dependent people on the prescription pain pills were white, many middle- to upper-income, Hansen said. 

Around the same time, the Drug Addiction Treatment Act of 2000 (DATA 2000) had passed, allowing physicians to treat opioid addiction with narcotic medications such as buprenorphine, lifting a more than 80-year ban on opioid prescription since the 1914 Narcotics Tax Act banned it.

The law, however, kept the methadone system restricted to DEA-regulated clinics with direct observation of patients who have to go to the clinics daily.

“This remarkable legislative change marked a clear shift away from the ‘war on drugs’ policy and rhetoric that had dominated US drug policy for decades,” write Hansen and Julie Netherland in the 2017 study “White Opioids: Pharmaceutical Race and the War on Drugs That Wasn’t,” published in the journal BioSocieties.  

They continue: “The policy responses seen as appropriate for Black and Brown addicts – methadone and prison – were not seen as a viable option for White addicts. New alternatives were needed, and DATA 2000 provided them.”

Hansen said the makers of buprenorphine successfully lobbied lawmakers to classify buprenorphine as a Schedule III drug, indicating a moderate to low potential for dependence. Methadone, meanwhile, remains a Schedule II drug, with a high potential for abuse.

To prevent the illicit use of buprenorphine, the drug’s manufacturer along with the federal Substance Abuse and Mental Health Services Administration developed an eight-hour certification course that doctors are required to complete in order to prescribe the medication. 

The certification became yet another barrier for free clinics or clinics that serve low-income patients, because those clinics don’t provide time or incentives to pursue this kind of certification, Hansen said. 

“The shortage of public sector prescribers, along with the cost of buprenorphine itself have long kept buprenorphine in the private sector,” she said. 

In April 2021, the Biden administration released federal guidelines that will eliminate the required eight-hour training course, also called the X-waiver, for prescribers.

Several national organizations, including the American Medical Association and the American Society of Addiction Medicine applauded the guidelines and said that its a step in the right direction. 

Years of research show disparities

More than 400,000 people in the U.S. receive methadone. To receive the treatment, individuals have to show up every day for 90 days to receive their dose. Only after that, they’re able to take home a weekly bottle. To get a full month’s worth of take-home methadone, individuals need to have been going to the clinic for two years. 

“So if you could imagine driving to a clinic, standing in line for an hour, an hour and a half, and then going to work every single day, seven days a week? It disrupts everything. It disrupts your ability to have a job, to take care of your kids,” said Dr. Ruth Potee, director of addiction services at Behavioral Health Network in Massachusetts during the virtual presentation hosted by the National Press Foundation. 

“I’ll be honest, I really think a lot of it is based on racism,” said Potee. “And if there’s a racial justice component to substance use disorder for me, it’s methadone.”

The first national study to show the racial identity associated with each medication was a 2006 report by the federal Substance Abuse and Mental Health Services Administration, showing that 91% of buprenorphine patients were white, compared with 53% using methadone as maintenance therapy. The report also showed that 56% of buprenorphine patients were college educated, compared with 19% of methadone patients. 

Less than a decade later, Hansen and her colleagues showed that the disparities persisted in their 2013 study, “Variation in use of Buprenorphine and Methadone Treatment by Racial, Ethnic and Income Characteristics of Residential Social Areas in New York City,” published in the Journal of Behavioral Health Services and Research. 

They found that across all ZIP codes in New York City, buprenorphine treatment was concentrated in areas with the highest incomes and highest percentage of white residents. In contrast, methadone treatment rate had an inverse geographic distribution in low-income, ethnic minority neighborhoods. 

In 2016, Hansen and colleagues once again showed the disparity in the study “Buprenorphine and Methadone Treatment for Opioid Dependence by Income, Ethnicity and Race of Neighborhoods in New York City,” published in the journal Drug and Alcohol Dependence

The team examined the uptake of buprenorphine compared with methadone treatment between 2004 and 2013 by income, race and ethnicity in neighborhoods in New York City.

They found that although buprenorphine treatment rates had increased across areas, it had a slower uptake in moderate income and mixed ethnicity areas. Methadone rates, meanwhile, had remained stable over time. 

“If there’s a racial justice component to substance use disorder for me, it’s methadone.”

Dr. Ruth Potee

In 2019, nearly 15 years after the 2006 report by SAMHSA, yet another study showed the racial disparities in buprenorphine treatment compared with methadone. 

In “Buprenorphine Treatment Divide by Race/Ethnicity and Payment,” published in JAMA Psychiatry in 2019, researchers showed that between 2004 and 2015 buprenorphine treatment was concentrated among white people and those with private insurance or the ability to self-pay. They found that between 2012 and 2015, 95% of doctor visits for buprenorphine were by white patients and only in 19% of the cases Medicare or Medicaid paid for the visit. 

Although Medicaid covers buprenorphine, its reimbursements are low, discouraging many to participate in the program or accept patients who have Medicaid. 

The disparities were confirmed in “Treatment for Opioid Use Disorder in the Florida Medicaid Population: Using a Cascade of Care Model to Evaluate Quality,” a study published in 2020 in The American Journal of Drug and Alcohol Abuse

“Older individuals and those who are black are less likely to receive a primary diagnosis and consequently are less likely to receive treatment for [opioid use disorder],” researchers write. “People who are dually eligible for Medicaid and Medicare are also less likely than people who are Medicaid eligible only to receive a primary diagnosis of OUD.” 

And yet another study, “Association of Racial/Ethnic Segregation With Treatment Capacity for Opioid Use Disorder in Counties in the United States,” published in April 2020 in JAMA Network Open, researchers showed that between 2018 and 2019 methadone clinics were significantly more likely to be located in highly segregated Black and Hispanic/Latino counties, while facilities providing buprenorphine were significantly more likely to be located in highly segregated white counties. 

“The differential availability of medications for [opioid use disorder] across U.S. counties represents an additional iteration of racism in the design and provision of health care services,” the authors write. 

In the Hispanic and Latino community, language barrier compounds the issue, explained Dr. Pierluigi Mancini, during the virtual presentation hosted by the National Press Foundation.

“When you’re in crisis, when you are addicted, when you have a mental health issue, when you are suicidal, we revert back to our original language,” said Mancini, project director at the National Latino Behavioral Health Association. “Half of the foreign-born individuals in this country cannot access these services because the providers don’t have the linguistic capacity.”

There are also cultural literacy barriers. 

“I had a client who told me his addiction was because his ex-girlfriend put a curse on him,” Mancini said. “And he truly believed that and he struggled with every step of treatment for the first few weeks, but that was his belief. So, we had to make sure that we address them in a way that he would not stop treatment, but in a way that he would be able to understand what we were trying to teach him.”

The federal Office of Minority Health has National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care to help with health equity in various settings. 

“Having a bilingual bicultural clinician is the best solution,” Mancini said. 

In addition, there are not enough Hispanic doctors that have gone through the training to prescribe buprenorphine.

“So, if most Hispanics try and go to Hispanic doctors, especially if language is an issue, and if we don’t have Hispanic doctors in the buprenorphine registry even though they just expanded it, then we’re not going to be able to use buprenorphine to help people with opioid use disorder,” Mancini said. 

Looking ahead

Potee expected the issue of how methadone treatment is provided to be a hot topic this year, after the pandemic arrived in the U.S., causing interruptions in the daily access to the clinics.

“The rules and regulations regarding methadone were written 48 years ago and they have not changed in 48 years,” said Potee. “And it’s one of the most effective tools we have in our toolbox.” 

An April 2021 report by the George Washington University’s Regulatory Studies Center calls for the federal Substance Abuse and Mental Health Services Administration (SAMHSA) to extend the flexibility that it granted during the height of the pandemic by allowing patients to take their methadone doses home or consume it in an unsupervised setting. 

“We have patients in my methadone world who have said the following words: ‘I don’t want the pandemic to end. I don’t want everybody to get the vaccine because if that happens, my life will get worse because my life has been better under COVID,’” said Potee.

Hansen added that the media portrayal of people with substance use disorder has also contributed to the disparities. 

She and Netherland published “The War on Drugs That Wasn’t: Wasted Whiteness, “Dirty Doctors,” and Race in Media Coverage of Prescription Opioid Misuse,” in 2016 in the journal Culture, Medicine and Psychiatry, showing that Black and Latino individuals were more likely to be characterized as criminals and drug users by the media, while suburbanites addicted to OxyContin were consistently portrayed as victims of over-prescription or people struggling with real or existential pain.

“Journalists must do better at noticing the racism inherent in their coverage of the opioid epidemic and becoming more conscious of implicit bias in their reporting,” the authors write. “They can start by making sure that their portrayals of people who use drugs are fair and equitable across race and class.” 

Additional studies to consider

Medications for Opioid Use Disorder Save Lives: The fifth chapter of this book, published in 2019 by the National Academies of Science, Engineering, and Medicine, provides an in-depth review of barriers to broader use of medications to treat opioid use disorder. 

Drug Dependence, a Chronic Medical Illness”: This widely-cited study, published in JAMA in 2000, argued that addiction was comparable to other chronic diseases like diabetes and hypertension and needed to be treated as such. 

Buprenorphine Treatment for Opioid Use Disorder: An Overview”: The study, published in 2020 in the journal CNS Drugs provides a review of the drug and discusses Naltrexone, another FDA-approved drug for treatment of opioid addiction. Naltrexone is different from buprenorphine and methadone in that it requires the patients’ full withdrawal from opioid. Methadone and buprenorphine remain gold-standard treatments for opioid addiction. 

Opioid Treatment Deserts: Concept development and application in a US Midwestern urban county”: The study, published in May 2021 in PLoS One, used opioid overdose data from the Columbus Fire Department in Franklin County, Ohio, between 2013 and 2017, showing geographic areas with little or no access to treatment and recovery services. (Visit Pew Charitable Trust’s 2018 map of methadone clinics in the U.S. to see disparities in accessibility of the clinics in the Midwest.) 

Statutes, Regulations and Guidelines for medication assisted treatment (MAT) opioid treatment programs: This website by the federal Substance Abuse and Mental Health Services Administration offers a list of rules and regulations around opioid treatment.

Methadone in Primary Care — One Small Step for Congress, One Giant Leap for Addiction Treatment”: This perspective, published in 2018 in the New England Journal of Medicine, argues that methadone treatment should be available in primary care practices in the U.S., just like Great Britain, Canada and Australia. 

Source list for this piece

Dr. Stephen Taylor: chief medical officer of behavioral health division at Pathway Healthcare, an addiction and mental health treatment center in Birmingham, Alabama, and Medical Director of Player Assistance and Anti-Drug Program at the National Basketball Association. Here’s Taylor’s National Press Foundation presentation.

Dr. Jessica Isom: clinical instructor of psychiatry at Yale School of Medicine, a community psychiatrist and consultant for diversity, equity, inclusion and antiracism projects. Here’s Isom’s National Press Foundation presentation.

Dr. Helena Hansen: professor and associate director of Center for Social Medicine and Humanities at David Geffen School of Medicine at UCLA. Here’s Hansen’s National Press Foundation presentation.

Dr. Pierluigi Mancini: project director at the National Latino Behavioral Health Association. Here’s Mancini’s National Press Foundation presentation.

Dr. Ruth Potee, director of addiction services at Behavioral Health Network in Massachusetts. Here’s Potee’s National Press Foundation presentation.