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



Reference:

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 https://www.cdc.gov/nchs/data-visualization/drug-poisoning-mortality/



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.

It Is Cold Outside

I was driving into work this AM. I drive a six year old Toyota Van. The thermometer on my rearview mirror hovered between - 20 and -21 Fahrenheit, but every bank I passed said -24. Before I left home this morning I added a layer of polyester, packed additional headgear, and wore my Sorel boots. This is serious weather even if you are born and raised here and you need to be prepared for the worst. Standing outside for even a few minutes without adequate cover can result in frostbite or worse. The Governor of Minnesota closed down all of the schools today to prevent frostbite injuries and so far there have been no arguments with that decision.  The drive home at night was slightly warmer at -16 degrees.  The sky was so clear it was like being in outer space.  I had to stop for gas and the driver's side door froze open.  I had to hold it shut for about 6 miles until it thawed to the point I could slam it.

Apart from the pragmatics of winter survival, the cold weather also triggers a lot of associative memories - starting with my Sorels. I got these boots originally in 1971 in order to do a Limnology experiment on Lake Superior.

A friend of mine helped me and we went out onto the ice for a about 5 hours and pumped about 200 gallons of lake water through a plankton net to look at the winter plankton population. It was about -5 degrees that day. A few years earlier he had a case of frostbite after walking about 10 blocks to school wearing nothing but a pea coat.  Like a lot of people in the northern US and Canada, I have found that these boots absolutely protect your feet in subzero weather.

I lived in Duluth, Minnesota for a while and can recall trying to speedskate when it was -10 to -15 degrees. At that temperature, a skate blade cannot compress and liquefy the ice enough to support much glide so the skating motion and its mechanics are seriously disrupted. I was wearing two layers of polyester, a layer of Lycra, and a layer of fiber.  Unlike Sorels - speedskates even with neoprene boot covers don't protect much against the cold.  When I got home I had to lay on top of a radiator under a blanket for 30 minutes in order to warm up. The coldest I have ever been in the winter usually happens after falling through the ice. I can recall walking across a creek and just getting ready to step up onto the far bank when I fell through the ice up to my chest in icy water. The sensation that occurs when that happens is incredible. Your breathing stops for a while followed by rapid gasping as you struggle to get out of the water. That is followed by the desperate run home. In my case it was only about 7 blocks and by the time I got there my clothes were frozen solid.  A friend of mine was skating on Lake Superior and fell through the ice catching himself only by his fingertips. He ran home about the same distance but he had been totally submerged.

My more recent memories are about how the cold has been a factor in my role as a psychiatrist. Most psychiatrists in the Midwest have first-hand experience with the complications of cold weather. We have seen people with frostbite injuries both on burn units and after they have been transferred. We know many of the people who are caught in the endless inpatient unit -> emergency department -> homeless cycle that seems like a permanent artifact of our managed care inpatient and county mental health systems. We have seen the human interest stories that tend to run in the papers when the potentially lethal cold weather hits and the temporary concern about whether or not there are enough shelter beds.

Weather this cold does not allow you to make a lot of mistakes. Sometimes all it takes is the idea that you can run out to the trash can without putting on a jacket and finding that you have locked yourself out of the house. People with memory problems and disorientation can wander off and get lost. People with drinking problems can pass out or just take too long to get home. All it takes is a decision that keeps you out in the subzero weather for minutes too long and you can be in serious trouble.

Potentially lethal cold weather is also an integral part of treatment decisions. You can't really watch people coming in to appointments wearing summer clothing in this weather without doing an assessment for cold weather safety. It becomes part of the discharge decision making. Exactly how stable is the person's housing and how likely are they to keep themselves safe? Can they walk 10 blocks from the hospital to their apartment wearing a sweat suit, basketball shoes, and no hat?  Should they be discharged to the street, even if they want to be?  Should they be discharged if a managed care reviewer says that they should be discharged?  We are generally talking about people who have chronic problems with insight and judgment.  What about people with suicidal ideation? What about the person with chronic drug problems who has a history of drug induced blackouts and waking up on park benches?  What about the person with Alzheimer’s disease who does not have 24 hour supervision?   

How do you make an unbiased decision in that context?  I can say that you don’t.  You don’t because as a psychiatrist you are aware of all of the adverse outcomes.  The continuum of severe frostbite injuries to the hypothermic who could not be resuscitated to those who were found frozen to death.  You don’t want to see that happen to anyone.  You don’t care if somebody wants to call that paternalistic.  You don’t really care if it costs a managed care company or (more likely) a hospital a few bucks.  You have been there yourself and you know you cannot take any chances in subzero weather.  It’s not about a fear of being sued, it’s about concern for a fellow human being.

There are implications for the imminent dangerousness standard that is commonly applied to involuntary holds.  I have argued with enough county attorneys over the years to understand that the standard itself is purely subjective and arbitrary.  No matter how it appears on paper you will hear ten different interpretations from 10 different county attorneys.  There are a few states where a gravely disabled standard applies.  That standard states that a person may have problematic judgment to the point that it potentially impacts their ability to secure adequate food, medical care, or housing.  That standard probably generally applies in these situations, but if you happen to be in a state where there is no statute or the county courts ignore it for convenience or financial reasons it may not be available for use.  

Those are the kinds of things I think about when it gets this cold.  I do get the occasional lighthearted thoughts – making sure I recall the thermodynamic equations that show my car battery dependent on temperature and telling myself that I am going to call Columbia and ask them if they make some type of expedition wear that is warmer than my current Titanium coat.  But mostly – I hope the most vulnerable among us get the help they need and nobody gets injured or killed.  Hopefully someday people will think about the fact that some people have a hard time protecting themselves - irrespective of the air temperature.

George Dawson, MD, DFAPA

Andy Rathbun.  Regions Hospital Sees "Record-Breaking" Number of Frostbite Cases.  St. Paul Pioneer Press.  January 6, 2013.

From the article:

"Most of the people that come in with severe frostbite are "in some way compromised," he said. A small number are physically or mentally disabled, but a majority are people who have consumed too much alcohol or were abusing drugs and didn't realize how cold it was outside, Edmonson said."