Monday, May 7, 2018

The Whitening of the Opioid Epidemic....

I was reading the most recent copy of the Psychiatric News (May 4, 2018) when a story jumped off the page at me.  It was called "How the Opioid Addiction Crisis Was Rendered 'White'.   I knew I had to post about it here because it contains several inaccuracies that typically occur when racial explanations are used to look into any complex phenomenon.

The article is about positions espoused by Helena Hansen, MD, PhD and in fairness it was not written by her.  There is no guarantee that she might consider these accurate depictions of her positions.  The article starts out discussing a 2015 PNAS article on mortality in white middle aged Americans (1) and what the authors termed "deaths of despair" claiming that the new opioid crisis affects these people "linked with social and economic causes: decreasing wages, disappearing jobs, and a diminishing standard of living."  In the same paragraph, the author points out that rate of increase of opioid related deaths is occurring in 55- 64 year old African Americans (see the recent respective slopes in the top 2 graphs used in the article).  For completeness, I suggest going through this data visualization and generating graphs for all of the age ranges, looking at absolute rates and the rate of increase, and comparing those generated graphs to the total deaths bar graph above it.

Dr. Hansen spells out a selective marketing strategy of opioids to white Americans - specifically selling them OxyContin as an opioid painkiller with minimal addictive properties in the 1990s.  She said that was followed up with selling white Americans buprenorphine as  a treatment for addiction.  She describes this as the "whitening" of a new class of opioids "against a backdrop of a long history in which heroin and other drugs of abuse were similarly "racialized" as the substances of choice among blacks and other minorities...."  The racializiation was accompanied with "sinister criminal imagery that ignored the socioeconomic circumstances that had always contributed to addiction in minority communities."

She suggests this racialization or whitening of the opioid epidemic was made possible by:

1.  Deliberate ethnic marketing by Big Pharma.
2.  The pharmaceutical "magic bullet" approach or buprenorphine as a solution to the opioid problem obscuring psychosocial and economic factors.
3.  A health care system that does not make psychosocial treatments equally accessible by "geography, class, or race".

She goes on to point out that the distribution of methadone versus buprenorphine has an unequal distribution with methadone being more inconvenient and distributed primarily in inner city neighborhoods.  Buprenorphine on the other hand is easier to take and is distributed primarily in the suburbs and is more easily available to the white middle class.

She brings up a familiar refrain that promoting addiction as a brain disease devoid of environmental or psychosocial context that "anyone" can get - is really code for "anyone" = "white".  She suggests that white opioid crisis has stimulated discussion of of economic revitalization for the white victims of addiction while the black victims were criminalized.  She concludes that addiction is rooted in "social problems mediated by mental illness" and therefore we need psychiatrists to address this problem.

As an addiction psychiatrist I have addressed all of these themes on this blog in the past.  I can make it as straightforward as possible.   All of the social, economic, and psychosocial explanations of addiction are highly flawed simply because the vast majority of Americans laboring under those conditions do not become addicted.  As far as I  can tell economic revitalization is political rhetoric, especially in the current circumstances where what the government will actually do to address the opioid crisis remains unclear. 

There are two critical variables for addiction.  The first is biology.  There are strong genetic components that correlate with addiction as well as some epigenetic components.  Race is not a factor.  On that same spectrum, genetics determine that some people are protected against addiction by their biologically determined reactions to addictive drugs and alcohol.  This is not speculation on my part it is a known historical fact and scientific fact.  No matter who you are or what your race is - you need this biological disposition to addiction or it probably is not going to happen.

The second variable comes down to exposure.  If there is no exposure of addiction prone individuals to the addicting drug there is no addiction.  That is where Dr. Hansen is partially right.  When Big Pharma targeted physicians to prescribe opioids for trivial pain and maintenance opioids for chronic noncancer pain that brought opioids to a much larger group of people, basically non-metropolitan whites who started to die in rural areas of opioid overdoses.  And it was much more than opioids.

The example I use in my lectures is a teenager in rural northern Minnesota in the 1970s versus today.  Let's say he knows his grandfather died of alcoholic cirrhosis and his father is an alcoholic.  What would he need to do in order to avoid being an alcoholic or addict in the 1970s versus today?  In other words if we assume his genetic make-up is the same and he inherited the family predisposition to alcohol misuse - what does he have to avoid?

In the 1970s there were basically three things: alcohol, tobacco, and cannabis.  In some areas of the country there was an amphetamine epidemic but that had not reached the northern frontiers of the US.  How about in 2018?  Today he has to avoid everything - opioids, alcohol, tobacco, cannabis, synthetic cannabinoids, amphetamine, methamphetamine, and everything he can acquire over the Internet.  We have gone from a country where rural (and white) Americans were relatively sheltered from all of these addictive compounds to where they are widespread and easily accessed.  So easy in fact that you can get many of them (opioids, amphetamines, benzodiazepines) directly from your physicians office.

I disagree with Dr. Hansen's basic theory of this opioid epidemic and how it was "whitened."  This is not a racial issue at all.  As I have been telling my students for nearly a decade now - "Until recently - why was a kid in northern Minnesota relatively protected against opioid addiction relative to a kid in the inner city?"

The answer is that kid in Minnesota - until recently - did not have to walk past any drug dealers on the way to school.

Now they do and the only relevant equation is biological predisposition + exposure = addiction.  That same simple equation is also the most compelling argument against legalization of addictive drugs because by definition it would mean a larger percentage of addictions with increasing exposure.

Men discriminate based on arbitrary definitions of race and class.

Biology does not. That is why anyone white or black can develop an addiction.

George Dawson, MD, DFAPA


1:  Case A, Deaton C. Rising midlife morbidity and mortality, US whites.  Proceedings of the National Academy of Sciences Dec 2015, 112 (49) 15078-15083; DOI:10.1073/pnas.1518393112

2:  Moran M.  How the Opioid Addiction Crisis Was Rendered White.  Psychiatric News, May 4, 2018, pages 19 and 23.

3:  Greene, Eddie L.Thomas, Charles R. et al.  Minority Health and Disparities-Related Issues: Part I
Medical Clinics of North America 2005, Volume 89 , Issue 4 , xi - xii

4:  Greene, Eddie L.Thomas, Charles R. et al.  Minority Health and Disparities-Related Issues: Part II
Medical Clinics of North America 2005 , Volume 89 , Issue 5 , xi - xii

Graphics Credit:

1:  National Center for Health Statistics - Drug Poisoning Mortality in the United States, 1999-2016

Supplementary (too tedious for the post).

Dr. Hansen
Dr. Dawson
Deliberate targeting of white people by Big Pharma marketing
Influence was at the physician and institutional level.  Increased access at many levels increased exposure to all Americans. Goal of the pharmaceutical industry is to develop “blockbuster” drugs by marketing and selling to as many physicians and patients as possible.
The pharmaceutical "magic bullet" approach or buprenorphine as a solution to the opioid problem obscuring psychosocial and economic factors.
If it was marketed that way – it was a poor job considering the number of overdoses that could have been prevented since it was released in 2002.  Even today there is widespread reluctance to prescribe it and use it and large social media groups advocating to not use it or taper off it. It is prescribed without considering the race of the patient.  In healthcare systems, a focus on a medication is frequently a way to not provide necessary services for anyone.  The obvious example is closing state mental hospitals and focusing on the success of chlorpromazine. 
A health care system that does not make psychosocial treatments equally accessible by "geography, class, or race".
The problems with racial and class disparities in care have been widely known and occurred long before the current opioid epidemic (see ref 3 and 4).  Government sanctioned managed care system has been rationing mental health and addiction care for 30 years for corporate profitability.  Despite continuous discussion of the epidemic there is little evidence that the infrastructure or service for treating addiction has improved in any way. 
No broader cultural theory.
Increased cultural permissiveness for drug use as evidence by widespread legalization of cannabis and the promotion of addictive drugs as therapeutic agents can increase the likelihood of illicit use.
Distribution of methadone clinics versus Suboxone prescribers
Suboxone is clearly more convenient but access to prescribers is very limited.  Suboxone patients often have to travel as far as they would have to get to a methadone clinic and then see a provider who does not accept health insurance and charges ala carte fees for service.  A segment of Suboxone users may do better on methadone.
Medical definition of addiction as a neurobiological disease that anyone can get was invented for white people.
Clearly applies to everyone unless you believe that there are some racial characteristics to suggest that one race is more susceptible than another.  As is the case with the majority of human illnesses I don’t believe there are any susceptibilities to acquired illness based on race.
Mental illness is a product of socioeconomic circumstances and a precursor to addiction.
In genetic studies mental illness co-aggregates with addictive disorders, genetic susceptibility to one increases susceptibility to the other.

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