THE TYPICAL face of America’s opioid epidemic has long been that of a white man from a post-industrial town in the Appalachian mountains. White victims have accounted for 78% of the more than 500,000 opioid-overdose deaths since the late 1990s. In 2017 counties in Appalachia experienced rates 72% higher than the average for the rest of the country.
African-Americans were, for once, far less affected. But that has changed. In 2020 their rate of opioid-related deaths surpassed white people’s—the culmination of a grim trend some five years in the making.
The first wave of the epidemic was caused by drug companies and doctors pushing prescription opioids. Researchers theorise that twisted beliefs (that African-Americans are more likely to divert pills for street use, and are less sensitive to pain so do not need them anyway) helped to insulate them from the scourge relative to white Americans. Then, from 2010, came a second wave: as regulators clamped down on prescription pills, many addicts turned to illicit opioids, notably heroin. White addicts continued to fatally overdose at over twice the rate of black users.
Fentanyl, a synthetic opioid up to 50 times more potent than heroin, brought a third wave. Though it is also a prescription painkiller, its illicit form—mainly made in Mexico with materials from China—has contaminated drugs. Its low cost and powerful high make it attractive: dealers can dilute the more expensive drugs they sell, such as cocaine, heroin or methamphetamine, while strengthening their effect.
Especially so for older black men. In 2020 black men aged 55 to 64 died at over 2.5 times the rate of older white men. Andrew Kolodny, medical director of opioid-policy research at Brandeis University, describes some of these victims as survivors of the heroin epidemic that devastated inner cities in the 1960s and 70s. Unaware that a more powerful synthetic opioid had contaminated their supply, “older black men who managed to beat the odds and survive for decades started dying,” explains Dr Kolodny.
George (not his real name), a 55-year-old West Baltimore native, has struggled with addiction since he was a teenager. In the four decades since he was first handed powdered heroin wrapped in a dollar bill the landscape has changed: “You used to be able to get a quality bag of heroin. Now you have this synthetic drug out here on the streets everywhere.” He now uses fentanyl regularly and estimates he has overdosed on it four times in the past couple of years. “When you’re messing with this stuff, everything’s a blur,” he says. “I don’t know how I keep outliving people, but I really don’t want to leave this Earth an addict.”
The poison has crept into stimulants, too. Overdose deaths attributed to psycho stimulants used with opioids have risen. Some are referring to this as a fourth wave of the epidemic. For those unaccustomed to opioids or “speedballing” (mixing stimulants with opioids), fentanyl is “a shock to the system, shutting down your breathing and heart rate”, says Keith Humphreys, a professor of psychiatry at Stanford University. Some 35% of African-Americans who died of overdoses in 2020 had both cocaine and fentanyl in their system, compared with 16% of white victims.
Poor people are more than twice as likely to die of opioid overdose. One-fifth of African-Americans live in poverty. Fully 40% of all homeless people and 38% of prisoners are black (compared with just 13% of the overall population). These are all potent risk factors. And though an estimated 65% of America’s prisoners suffer from a substance-use disorder of some sort, there is little access to good treatment either during incarceration or upon release.
Treatment for opioid use disorder (OUD) is woefully inadequate across the country, but African-Americans often face extra barriers. Studies have found that medications for treating OUD, as well as naloxone (a life-saving medication that reverses opioid overdoses), are doled out unevenly. A study of data from Medicaid, the government insurance programme for the poor, across several states with some of the highest opioid-overdose rates found that between 2014 and 2018 black people with OUD were 28% less likely to use OUD medications.
Studies in various cities, including San Francisco and Los Angeles, suggest that African-Americans have less access to naloxone, too. In Detroit between 2019 and 2020, white addicts received 28% of naloxone administrations, though they accounted for 17% of the city’s opioid overdoses; although 80% of overdoses were among black people, they received only 67% of naloxone administrations. This does not necessarily mean black addicts are being denied naloxone. Those who use opioids alone, are homeless or live in communities with little trust in first responders might be less likely to call for help.
Such disparities strengthen the case for local interventions that deal with the unique hurdles certain communities face. Other solutions are more sweeping, like expanding access to Medicaid and reducing red tape around OUD medications. But underlying all these is a straightforward calculus that applies to all Americans, black or white: “It has to be easier to get treated than it is to continue using,” says Dr Kolodny. “You have to flip it.” ■
This article appeared in the United States section of the print edition under the headline “A lethal shift”