The racial divide in the opioid crisis

The city of Huntington, a community of nearly 50,000 located in western West Virginia, over the past several years has felt the harsh impact of the nation's drug abuse crisis.

The state's rate of death from drug overdose rose by 65% between 2009 and 2013. Huntington lies within one of the most heavily affected counties (PDF), where more than 900 people overdosed in 2015. Seventy of them died.

Jim Johnson has seen, firsthand, how the face of drug abuse in Huntington has shifted over the years.

“I came onto the police department in 1972, and the people ... on heroin were that part of society that you were walking down the street, and you would want to go to the other side,” said Johnson, who is now the director of the Mayor's Office of Drug Control Policy for Huntington. “Now there has hardly been a family that has not been affected.”

That reflects the scope of the epidemic. The rate of heroin-related overdose deaths throughout the country has nearly quadrupled since 2002. An estimated 30,000 people every year die from opioid overdoses.

But unlike drug epidemics of the past, minority populations have seen a less dramatic increase in addiction and deaths when compared to white young adults. The rate of heroin use among white adults increased by 114% between 2004 and 2013, according to the Centers for Disease Control and Prevention, while the rate among nonwhite adults remained relatively unchanged during that same period.

Dr. David Rosenbloom, professor of health policy and management at Boston University's School of Public Health, thinks he knows why. “Blacks have been undertreated for pain for decades,” he said.

The stark rise in addiction can be traced back to the increased the use of the prescription pain relievers OxyContin and Vicodin. Prescriptions of opioid analgesic medications have skyrocketed since the introduction of OxyContin in the mid-1990s. In 2012, the number of prescriptions written for opioid drugs reached 259 million.

Regulators only a few years ago began implementing stricter limits on the number of pain pills doctors could prescribe, which resulted in lower prescribing rates for opioids, but also led to a subsequent rise in heroin use, a cheaper and easier option than prescription pain medicines.

A 2008 JAMA study found minorities were less likely to receive opioids for pain in an emergency department compared to whites.

Some say physicians' prejudice leads many to prescribe opioids at a lower rate to black and Latino patients than to whites.

“It would appear that the prescriber may be more concerned about the possibility of the patient getting addicted or maybe the possibility that the pills will be diverted and sold on the street if the patient is black. If the patient is white, they may feel like there's nothing to worry about,” said Dr. Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing.

Still others contend the problem may have more to do with white patients having traditionally had greater access to healthcare services compared to minority patients, increasing the likelihood of receiving pain treatment.

“It could be that overall ability to be able to be prescribed these medications has resulted in more exposure among whites and more risks in terms of addiction and overdose,” said John Kelly, an associate in psychiatry at Massachusetts General Hospital, Boston.

Many believe the changing face of drug abuse is behind the urgent call to action among presidential candidates, lawmakers and law enforcement officials. That would also be true for the increased call for treatment rather than the previous “war on drugs,” which concentrated on mass arrests and incarceration.

“I think it was pretty clear that our response during the crack cocaine epidemic was largely a criminal justice response,” Kolodny said. “Whenever you hear people talking about our opioid crisis, within the first few minutes you hear someone say to the effect that we can't arrest our way out of this problem.”

Democratic presidential candidates Hillary Clinton and Vermont Sen. Bernie Sanders have both called for plans that include “rehabilitation and treatment” over prison for low-level and nonviolent drug offenses.

Republican presidential candidate Texas Sen. Ted Cruz, whose half-sister died from a drug overdose, has called for faith-based treatment. GOP frontrunner Donald Trump supports treatment and prevention efforts, and like Cruz, has advocated for securing the U.S. border to disrupt the drug supply.

Treatment-based solutions to address addiction have already begun to take shape. A total of 42 states and the District of Columbia have passed legal protections for medical professionals who dispense naloxone, a prescription drug that counters the effects of an opioid overdose. Controversial measures, such as needle exchange programs for drug users, have gained support in states and municipalities across the country.

For places like Huntington, needle exchange programs have helped combat another health issue related to intravenous drug use. In 2013, West Virginia had the highest rate of hepatitis B infections in the nation with 10.5 cases for every 100,000 residents, according to the CDC. By comparison, the state with the second highest rate of hepatitis B infections that year was neighboring Kentucky, which had 4.9 cases per 100,000.

Nationally, rates of hepatitis C infection have increased as more Americans have turned to using intravenous drugs. Rates of infection in four states—Kentucky, Tennessee, Virginia and West Virginia—rose by 368% between 2006 and 2012, according to the CDC. Intravenous drug use was cited as a risk factor in 73% of those cases.

Johnson admits he was not initially a big supporter of programs aimed at harm reduction for substance abusers. What changed his mind toward adopting more of a public health approach was witnessing the devastating effects the drug epidemic was having throughout the entire community.

“In our county we were spending at a minimum of $50 million to $100 million a year just on the healthcare,” Johnson said. “When we started talking about syringe exchange it was like, 'Why aren't we doing this.' ”

Changes in the country's approach to drug abuse have also come from a national level. President Barack Obama earlier this month proposed allocating $1.1 billion over two years as part of his fiscal 2017 budget toward fighting heroin and opioid drug abuse; $920 million of that would expand medication-assisted treatment.

But the question remains whether the country has truly turned a corner in how it perceives addiction and whether the current approach will be applied to any future drug epidemics affecting all racial groups.

“I would like to think it would help to shift the climate somewhat, but I am not overly optimistic,” said Marc Mauer, executive director for the Sentencing Project, a research organization that advocates for reforms in the criminal justice system. “We still have a ways to go I think to broaden that perspective on how we approach substance abuse.”