By Taylor Knopf
State officials announced last month that more than 12,000 people with substance use disorder entered addiction treatment since North Carolina received $54 million in federal grant funding to address the opioid crisis.
Opioid addiction is widespread in North Carolina, and an average of five people die per day from overdose. It affects people across the state from every race and socio-economic background.
However, the majority of people benefiting from the grant treatment money are white.
The state health department collected demographic data on 10,333 people who entered substance abuse treatment over the past two years through the 21st Century Cures Act State Targeted Response to the Opioid Crisis Grants.
Of those served by the grant, 9,085 (or 88 percent) were white, while 775 (or 7.5 percent) were African American. Fewer than 1 percent of the beneficiaries were American Indians.
Meanwhile, the rate of overdose deaths among American Indians in North Carolina was 1.3 times higher than the overdose rate among the total state population from 2000 to 2016, according to a recent article in the North Carolina Medical Journal.
Authors of the article in the NCMJ found that rates of hepatitis C infection among the American Indian population are also particularly high. The authors go on to point out that the state’s opioid action plan fails to mention the American Indian population, while addressing other special population groups, such as pregnant women.
White people receiving better access to certain types of addiction treatment is a trend seen across the United States as well.
Kaiser Health News reported earlier this year that white drug users had “near-exclusive access to buprenorphine” — also known as Suboxone, an addiction treatment drug — during a period when black people were dying from overdoses at higher rates than white people.
Public health experts attribute these disparities to several factors, including bias within the medical system and overcriminalization of minority drug users.
Doctors seeing black and white
In a recent Cureus medical journal article, authors of “Racial Bias in the US Opioid Epidemic: A Review of the History of Systemic Bias and Implications for Care” conducted a literature review of dozens of published studies and attempted to explain the discrepancies in access to treatment.
“Although public and medical professional attitudes have shifted since the crack cocaine epidemic of the 1980s to a treatment-focused resolution, similar issues regarding care equity remain,” the study authors wrote.
“One of the most significant obstacles that minority groups face in opioid abuse treatment is limited access to qualified healthcare providers who can assist with pharmacological treatment opportunities and medication-assisted treatments (MATs).”
They go on to explain the socio-economic differences between methadone and buprenorphine, the two most popular addiction treatments.
Methadone was first used in clinical trials on inner-city minorities to treat heroin addiction, the authors wrote. Many of the clinics are still located in minority communities, where their locations and the people who use the clinics are visible to the public. Furthermore, patients must visit them daily, adding to the burden of treatment along with creating added stigma. Additionally, methadone clinics are highly regulated by government authorities and largely funded by Medicaid, they explained.
“Treatment is complicated for Medicaid patients due to the inconsistent funding or time-restrictions that are imposed by Medicaid,” the researchers wrote. “This is detrimental to the patient as it can impede their success for treatment due to the higher chance of relapse with sub-optimal dosing of methadone.
“Additionally, even when access is available, non-white minorities utilize the services at half the rate of Caucasians due to the financial burden associated with overcoming multiple barriers,” they wrote.
Meanwhile, buprenorphine is a partial opioid antagonist, which makes it harder to abuse than methadone. It can be prescribed by physicians who undergo training to obtain a special federal waiver and are then willing to do special record-keeping. Until 2017, physicians were limited to only 100 patients who could receive the drug (currently, they can apply to prescribe to up to 275 patients).
“There are many factors that restrict the access of buprenorphine which include the provider access and payment by insurance,” the researchers wrote.
That extra training to prescribe Suboxone creates a barrier for care, they maintain. Currently, only about 7 percent of the nation’s physicians have been willing to take the extra time and effort.
“Additionally, since private practice physicians are more likely to be certified to prescribe buprenorphine, there is less likelihood that minorities have access to these treatments.” the authors wrote.
Less access behind bars
Some harm reduction advocates argue that minority drug users have less access to drug treatment because they are incarcerated at higher rates than white drug users.
According to the National Association for the Advancement of Colored People (NAACP), both African Americans and white people use drugs at similar rates. However, African Americans are incarcerated for drug-related charges at six times the rate of white people. Other sources suggest the rate discrepancy is even greater.
“As an African American, if I’m a drug user, what it means for me to be an injection drug user in America is not the same for someone who is white. And in America, it never has been,” said Virgil Hayes, advocacy and program manager with the NC Harm Reduction Coalition.
“Not everybody has the same level of access to these [treatment] services, and the reason why is a criminalization of certain populations,” Hayes said. “Unfortunately, this falls in lockstep with historical data that shows that not all drug users have been treated the same in America. In the ’80s and ’90s, in the crack era, a lot of black and brown drug users were criminalized.”
In 1986, the U.S. Congress passed the Anti-Drug Abuse Act which established mandatory minimum sentences for different quantities of cocaine possession.
“Congress also established much tougher sentences for crack cocaine offenses than for powder cocaine cases,” according to the American Civil Liberties Union. “For example, distribution of just 5 grams of crack carries a minimum 5-year federal prison sentence, while for powder cocaine, distribution of 500 grams – 100 times the amount of crack cocaine – carries the same sentence.”
African Americans were more likely to use crack cocaine, while white people were more likely to use powder cocaine.
As awareness has grown, there are now law enforcement diversion programs which allow some drug users to avoid arrest if they enter into addiction treatment.
“We need to increase programs like the law enforcement assisted diversion, and make sure there are people of color being invited into those,” said Michelle Mathis, co-founder of Olive Branch Ministry, a N.C. faith-based, harm reduction organization that focuses on outreach to people using drugs, the homeless population and the LQBTQ community.
Hayes added that there needs to be more education and addiction treatment services for those incarcerated.
“If we know that a large percent of people who are locked up for drug-related crimes are black and brown, why wouldn’t we have those services within jails and prisons?” he said.
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Excellent, well written article Taylor. Thank you! This article is chock full of information that further adds to my concerns about the negative (and possibly unintended) consequences that are sure to happen when H474–the Death by Distribution bill is signed into law. Those Black, American Indian and other persons of color who are not benefiting from treatment but who are most likely spiraling in their addiction and selling their prescription drugs to meet other needs i.e. rent, food, or to pay for an alternative drug e.g. heroine, will be the ones who are caught in the criminalization web that H474 creates. Thank you for shining light on a key part of many mental health and SUD advocates protests to H474–the treatment side of this crisis and who is or isn’t benefiting.
Maybe the lasting effects of Tuskegee?
Thank you for bringing up about this. This is not fair and we should raise our voice about this so called disparities. We should always open our eyes, discrimination can happen everywhere even in the Health industry.
No mention of addressing the root causes in communities for substance use. Until community determinants of health are addressed and supported by funders we will continue reacting to crisis after crisis. We can’t treat our way out of the problem (although inexpensive and easy access to treatment is essential). There are major systemic issues at work that have long been ignored. A willingness to invest in long term solutions needs to be a core component if social inequities are to be minimized. But, the system is built on short term, reactive responses primarily focused on a triage approach. Where is the leadership to do better?
A great article is full of facts and reality. I would like to get more from your research to expand on and bring out more into the public eye. I am an aspiring writer and professional speaker on this subject and many others.