I recently posted my take on this issue of race in addiction treatment. The main argument that I was responding to was that the current opioid epidemic is whitewashed so to speak. In other words white opioid addicts are considered to be "victims" of the opioid epidemic and black addicts are considered just to be addicts at best and criminalized at worst. Part of the way that white people are framed as victims is by calling addiction a disease. The author who I was critiquing at the time suggested that the opioid epidemic was marketed to white people along with the medication (buprenorphine) that would "cure" them. Further, that buprenorphine was more easily available to white people by the nature of the prescribing requirements. The article went on to selectively highlight one segment of the population where "non-Hispanic blacks" had a higher rate of overdose deaths, despite the fact that the majority of people dying in most categories were white. I consider my counterargument to be a solid one and that is - there is no known difference in the biological predisposition to addiction of any kind that is based on race and if that likelihood is equal - the only consideration is who is exposed to the drug.
The racialization of the opioid epidemic picked up more speed over the weekend. One of the theories proposed was that there were no previous "epidemics" of opioid use and that this is another way to sanitize the problem and make it more acceptable to white people. The article was written for a newspaper - the Guardian and the headline says it all: "Amid the opioid epidemic, white means victim, black means addict." That is the basic thesis that runs through the entire essay. You are either a white, Christian, Republican racist, who considers himself to be a victim of prescription opioid tablets or drug dealers or the hypocritical structure of American society insults you for being black and an addict. It is suggested directly in the article that common rationalizations of addicts - the ones that everybody uses irrespective of race or substance are the exclusively used by whites to deny responsibility for addiction. Self-loathing of the addict is described as though that never happens with white people. Guilt, shame, and self loathing happens to everyone with an alcohol or drug misuse problem.
A couple of the arguments can be debunked at the outset. The idea that the term epidemics is applied only to white people so that they can rationalize being victims ignores the medical literature of the 1970s. In those days researchers were using the terms epidemics and microepidemics and applying the terms across racial groups (3-6). Successful naturalistic studies were conducted in both white and black neighborhoods and the success in a Chicago study (6) was correlated with use of the term medical management. Those same authors used what they called an infectious disease model for intervening in heroin epidemics (5). The Chicago study was so successful that it was suggested as an alternative to involuntary treatment (4):
"This work suggests that heroin addiction can be prevented in many who are at risk; it further suggests that prevention may be possible by using psychological and social concepts based on humanist principles without the use of coercion. The authors' approach deserves close attention not only because it offers hope in the face of a mounting national tragedy but also because of its relevance in the current high-level and little-publicized debate over the use of compulsory urine testing and compulsory treatment of drug dependent persons." - p.1156
It appears that at least in psychiatry - humanism was emphasized as the critical element in treating drug dependent persons (not addicts) as far back as 46 years ago. The design of the naturalistic study in question was impressive and methadone maintenance treatment was used in a majority of the patients.
The issue of differences in the story about the self perception of a white versus black addict does not have the equivalent empirical basis. I can say unequivocally that any attitude in treatment about being a "victim" of substance use of any type would be vigorously confronted by treatment staff. It is not possible to actively participate in treatment with that attitude. The same is true of the self loathing patient. Guilt, shame, and self loathing need to be actively explored and corrected to allow participation in the recovery process. Both attitudes can lead to distress or increased cravings to use drugs and alcohol and relapse.
What about the contention that cultural differences and disparities are the primary problem with treatment differences. I refer any interested reader to an in depth analysis of the issues by Coleman Hughes (2) and what he describes as the disparity fallacy - in other words that the difference in outcomes between blacks and whites (or any two groups) is due to discrimination being the causal factor. He lists an impressive number of examples, but I see the underlying principle as being one of undeterminism (7) that is there are multiple theories to account for differences, and people tend to have a favorite and ignore all of the other possibilities. There is probably no better example than the race rhetoric around addiction. The promotion of these arguments ignores the primary causes of addiction - a biological predisposition and exposure to the addictive substance. I am not suggesting disparities are irrelevant to exposure or treatment access but focusing on them as casual ignores the major factors.
The continued stories about racial differences in treatment and self perception are not really conducive to reshaping America's addiction treatment landscape. It misses the big picture that there are no differences in race when it comes to addiction. Any reasonable treatment approach would disabuse anybody coming through the door who believed they were either a victim or a self-loathing addict. Identical treatment modalities should be offered irrespective of race and that includes medication assisted treatment of all types, necessary psychiatric and psychological treatment, medical evaluation and treatment, and drug and alcohol counseling focused on recovery. One of the reasons why addiction is viewed as a chronic illness is the high likelihood of relapse and need for ongoing recovery services and support. One of the main tenets of any 12-step recovery program based on the AA model is that nobody is turned away. The only requirement for membership is a desire to get sober.
The real problem with drug and alcohol treatment is not racial disparity. It would be fairly obvious if racial discrimination was occurring in any comprehensive treatment program. The real problem with drug and alcohol treatment is the lack of standards and consistency in treatment. The most clear cut example is the availability of detox services. Some forms of withdrawal are life threatening and need to be immediately recognized and treated. I doubt that the majority of treatment programs in any state have that capability. Hospitals have been defunded from providing detox services from anyone who is not experiencing life threatening withdrawal for about 30 years now. That has led to a proliferation of subpar and non-medical county detox facilities where limited to no medical care is rendered. These kinds of inconsistencies in care occur across the board and it is common to see patients who have not received even basic addiction care - completing a treatment program and being released back to their home setting.
Racism has no place in medicine. I have discussed the advantages of therapeutic neutrality on these pages before and certainly any physician who is not able to do that should not be practicing medicine in the 21st century. The psychiatric standard for neutrality is higher. Psychiatrists in particular are trained to understand cultural differences, but it is not possible to be an expert on every culture. It is possible to appreciate the person in the room and proceed cautiously enough to assure that culturally sensitive care is being provided.
In the end, there are clearly ways to prevent and treat addiction. Suggesting that race and the narratives around race are the primary factors that account for addiction or recovery is unfounded.
George Dawson, MD, DFAPA
References:
1: Brian Broome. Amid the opioid epidemic, white means victim, black means addict. April 28, 2018.
2: Coleman Hughes. The Racism Treadmill. Quillette May 14, 2018.
4: Freedman DX, Senay EC. Heroin epidemics. JAMA. 1973 Mar 5;223(10):1155-6. PubMed PMID: 4739378.
5: Hughes PH, Crawford GA. A contagious disease model for researching and intervening in heroin epidemics. Arch Gen Psychiatry. 1972 Aug;27(2):149-55. PubMed PMID: 5042822.
6: Hughes PH, Senay EC, Parker R. The medical management of a heroin epidemic. Arch Gen Psychiatry. 1972 Nov;27(5):585-91. PubMed PMID: 5080286.
7: Stanford, Kyle, "Underdetermination of Scientific Theory", The Stanford Encyclopedia of Philosophy (Winter 2017 Edition), Edward N. Zalta (ed.), URL = https://plato.stanford.edu/archives/win2017/entries/scientific-underdetermination/.
6: Hughes PH, Senay EC, Parker R. The medical management of a heroin epidemic. Arch Gen Psychiatry. 1972 Nov;27(5):585-91. PubMed PMID: 5080286.
