By Melba Newsome
John Woodyear is a primary care physician who specializes in addiction treatment. On most days, his waiting room at the Family Care Clinic & Associates is filled with patients waiting to get their prescription for buprenorphine, a medication to treat opioid substance use disorder (SUD) sold under the brand names Subutex and Suboxone.
Research shows that the medication can reduce the risk of overdose by half and double a patient’s chances of entering long-term recovery.
Woodyear estimates that more than 90 percent of his SUD patients are white. That would be expected in the nearly all-white counties in the western part of the state that have been hardest hit by the opioid crisis, or even if Woodyear was white.
But the 68-year-old physician is Black and practices in Troy, a town in Montgomery County that is 36 percent Black. The racial make-up of his patient population represents a disturbing fact about opioid addiction treatment: as people of color make up an increasing number of the people who misuse and develop an addiction to opioids, those who receive SUD treatment remain overwhelmingly white.
A marked change in addiction attitudes and policies
Since the current opioid crisis started unfolding in the late 1990s, addiction has increasingly been spoken of as a public health concern. The white, middle-class, suburban and rural populations that were most affected are portrayed as victims, both of overzealous prescribing of prescription opioids and unscrupulous pharmaceutical companies, who are deserving of compassion and care.
Even the language used to describe addiction is less stigmatizing; patients with substance use disorder are no longer referred to as “addicts” or “junkies.”
This is a marked contrast to the national response to the crack cocaine epidemic of the 1980s and the war on drugs, declared by Richard Nixon in 1971. For decades, addiction has been considered a personal “moral failing” that needs to be addressed by punitive measures and incarceration.
Those efforts criminalized substance use, particularly in Black communities. That more punitive approach was on display in the distinctions made between Black and white drug users prosecuted for possession of crack cocaine and powder cocaine in the 1980s. . Black people were prosecuted more frequently for crack cocaine, which carried longer and harsher sentences, than were whites for cocaine, which carried lesser penalties, even for greater quantities of drugs.
Attitudes around substance use only began to change once white communities started experiencing high rates of dependence and death from opioids. There are signs, however, that this more enlightened attitude and view of addiction does not extend to all opioid victims.
The changing face of the epidemic
The gap between the rates at which Black people and white people use and die from opioid overdoses has narrowed steadily in recent years. While the most recent NC DHHS data shows that white North Carolinians overdose deaths were twice the rate of members of the Black community, the rates were comparable on a national scale (19.0 and 17.1), according to data compiled by the Kaiser Family Foundation.
Those numbers flipped during the COVID-19 pandemic, according to preliminary data from the Centers for Disease Control and Prevention (CDC). For the first time in more than 20 years, the rate of Black overdose deaths surpassed that of whites.
So how and why did opioids, substances derisively called “hillbilly heroin,” become the drug of choice for Black people? The Agency for Healthcare Research and Quality (AHRQ) says virtually every street drug is now contaminated by synthetic opioids such as fentanyl and carfentanil, which are cheaper and more powerful.
Roadblocks to recovery
Shuchin Shukla, a faculty physician and opioid educator at the Mountain Area Health Education Center in Asheville, says the North Carolina General Assembly’s refusal to expand Medicaid has crippled the state’s ability to address SUD and overdose deaths.
“There’s plenty of research showing how overdose rates changed in states that expanded Medicaid,” says Shukla. “One way or another, the taxpayers are paying for this. We can pay through outpatient treatment, which is relatively cheap and medically and ethically sound, or we can pay for jails and prisons, ER visits, ambulance rides, HIV and Hepatitis C treatment.
“That is what North Carolina is currently doing.”
Much of substance use treatment services are funded by grants and philanthropic entities, which are inadequate to cover the need. As a result, a substantial share of federal grants are diverted to provide services that would otherwise be covered by Medicaid.
But even those grants are not distributed equitably. A $54 million federal grant allowed the state to provide treatment to 12,000 people, only 7.5 percent of whom were Black and less than 1 percent were American Indian, the population most devastated by the opioid crisis.
Many addiction medicine specialists see medication-assisted therapy (MAT) as the best hope for curbing opioid misuse and overdose. Because MAT drugs are also opioids, they satisfy the opioid craving and stave off withdrawal without producing that euphoric high. A variety of studies have found that MAT can cut the all-cause mortality rate among addiction patients by half or more.
There are many barriers to accessing this treatment in North Carolina, one of 11 states where buprenorphine prescribers per opioid death rates are well below the national average. Doctors are required to complete an eight-hour training program and get a waiver from the federal Substance Abuse and Mental Health Services Administration (SAMHSA) to prescribe buprenorphine for addiction; physician assistants and nurse practitioners require 24 hours of training.
The spike in overdose mortality during the pandemic, particularly among Black and Latinocommunities, led to several new initiatives and additional funding to train more health care providers to prescribe the drug. But getting more doctors on board remains a challenge.
Woodyear is federally certified to prescribe buprenorphine to up to 275 patients, the maximum allowed, and has tried to recruit more MAT providers to the closest population center, Pinehurst, without much success. He said he believes doctors have a “prejudice bias” toward treating people with addiction.
“They don’t want them in the office with their middle-class, upper-class patients,” he said. “They don’t want their waiting room looking like an arraignment court.”
Blake Fagan is chief education officer at UNC Health Sciences at MAHEC. He once vowed he’d never prescribe MAT because he saw it as substituting one addiction for another. After some tragic experiences with his patients, he changed his tune. These days, Fagan not only prescribes MAT, he sees that primary care doctors in residency programs in North Carolina are qualified to prescribe the drug, too.
Despite the widespread acknowledgement that SUD is a crisis irrespective of race and/or ethnicity, there are vast disparities in who has access to quality treatment and care. Few people of any race identified as needing SUD treatment actually receive it but the numbers are most abysmal for people of color: just 10 and 8 percent of Black and Latino individuals with substance abuse disorder, respectively according to data from SAMHSA. A 2019 national study published in JAMA Psychiatry reported that more than 97 percent of people prescribed buprenorphine in an in-office setting were white.
Medicare or Medicaid paid for the visits in only 19 percent of the cases.
Even people with private insurance encounter barriers to treatment. A cohort study published in JAMA Network Open found that only 16.6 percent of commercially insured patients obtained follow-up treatment after a nonfatal opioid overdose; Black patients were half as likely as whites to obtain a treatment referral.
The numbers are even more dismal for those who are uninsured or on Medicaid who have fewer options for substance use treatment. Although the Medicaid program covers the drug, low reimbursements discourage many providers from accepting patients who have the coverage.
Woodyear says he is one of the few providers of medications for opioid use disorder who accept Medicaid.
Buprenorphine and the once-a-month injectable Vivitrol are available in regular outpatient settings and mostly to people with private insurance. This was always the plan, says Tracie Gardner, senior vice president of policy advocacy at Legal Action Center which seeks to end punitive measures for health conditions like addiction.
“When people observed the uptick in opioid use disorder among white people, they determined that an office-based approach would be preferable because of the belief and stereotypes we have constructed around methadone maintenance,” says Gardner. “Methadone has been highly racialized and has a very complex and complicated history. It is still under the purview of the Drug Enforcement Agency whereas buprenorphine is treated like a medication to be offered through a health care provider.”
The racial disparities also extend to treatment outcomes. Only 28 percent of clients completed treatment, and the survey results indicate that Black and Latino people are less likely to complete treatment compared to whites. The lack of racial diversity among treatment providers is also a factor. There is a dearth of treatment providers who can address the needs of racially marginalized patients and offer treatment services that take their cultural identity into account.
Drug overdose deaths topped 100,000 in a one-year period during the pandemic for the first time ever, according to provisional data released by the CDC in mid-November.
“That’s probably way underestimated just like the number of deaths from COVID is probably way underestimated,” Woodyear said. “We’re dealing with an epidemic that we need to bring the same energy to treating as we have brought to the pandemic.”
This story is part of a reporting fellowship on health care performance sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund.