A version of this piece originally appeared in Luke O’Neil’s newsletter Welcome to Hell World, which, like Discourse Blog, is a member of the Discontents media collective. Click here to subscribe.
Public health researchers and economists have proven a link between reckless opioid overprescribing and the astronomical rise of overdose deaths in the United States. A recent CDC report shows that drug overdose deaths in the U.S. have reached an all-time high – more than 100,000 in one year. Three quarters of these overdose deaths were caused by illicit fentanyl and its analogues. Fentanyl, a synthetic opioid 50-100 times stronger than morphine, now comprises the majority of what’s commonly referred to as “street heroin.”
The prescription opioid use to illicit opioid use pipeline is real and shouldn’t be dismissed. But the popular narrative of this specific trajectory has been mythologized and distorted by the media, law enforcement, and policymakers to delineate “good” drug users and “bad” drug users. Unsurprisingly, this categorization falls along predictably prejudiced lines. According to the myth, the “good” are often white, middle or upper class, and live in suburbs. They are not inherently “addicts” but are innocently led to their drug use through the overprescribing of opioids by societal and market forces beyond their control. The “bad” are most often Black, brown, or poor and live in cities. They are drug users who start with illicit drugs and are therefore considered inherently criminal “addicts.” The “good addict/bad addict” narrative is not only erroneous and discriminatory, it is also the continuation of a long history of misleading mythmaking in the U.S. that has resulted in punitive drug policies that disproportionally hurt Black, brown, and poor people.
I have personally witnessed the “good addict/bad addict” paradigm play out throughout my life. In addition to my own lived experience with poverty, homelessness, and addiction, I also worked twelve years serving high-risk populations for the City of Boston, including five years as Policy Director for the Mayor’s Office of Recovery Services. In more recent years, as the opioid epidemic worsened, I would increasingly hear people talk about how today’s drug users come from “good families” and are “not the typical addict.” I can’t tell you how many times I heard about the sports injuries and surgeries that led people to OxyContin and eventually to injecting fentanyl. This all sounded like thinly veiled attempts to retain a fantasy of white, middle-class innocence. The people talking this way were almost always middle-class white people. I heard it most often from law enforcement.
Every time I heard this innocence trope parroted back to me, I’d think about how my own addiction was criminalized and shamed. I’d also think about the high-risk youth that I served for years at the City of Boston, almost all of whom were Black and brown. They received far worse treatment than I did as a white court-involved youth. The kids I worked with, despite facing a staggering amount of trauma and adversity, were never afforded the compassion and leniency that suburban white drug users were. Instead they were often incarcerated for the same crimes white youth would be diverted for.
What’s at the heart of the “good addict/bad addict” myth? And why the incessant need to create a caste system of drug users based on the substance that they use?
When we start asking questions like these, we get to a painful truth about drug use in the US, which is that our social systems create stark inequities for poor people and people of color, and those inequities cause severe adversity and pain. Addiction expert Dr. Gabor Mate often says, “the question is not why the addiction, but why the pain?” It’s a lot harder for people to sit with this question because it requires grappling with larger injustices, which may render us all complicit. It’s more desirable then to avoid this difficult work and blame “bad addict” behavior on individual moral failings. Another addiction expert, Maia Szalavitz, writes of this tendency in her book Unbroken Brain:
[A]ddiction is not simply a result of exposure to a drug…The critical risk factors for addiction are child trauma, mental illness, and economic factors like unemployment and poverty. The ‘innocent victim’ narrative focuses on individual choice and ignores these factors, along with the dysfunctional nature of the entire system that determines a drug’s legal status.
The creation of an American caste system, based upon select populations using specific drugs, is not new. The tragedy of the crack epidemic is a prime example. In Crack in America, Craig Reinarman and Harry Levine write that by 1985 “more than twenty-two million Americans in all social classes and occupations reported at least trying cocaine.” The authors note that, even though people from all backgrounds were smoking cocaine and crack, crack only “attracted the attention of politicians and the media because of its downward mobility to and increased visibility in the ghettos and barrios.” They further describe how this disparity was reinforced by the media. By 1986, “dramatic footage of black and Latino men being carted off in chains, or of police breaking down crackhouse doors, became a near-nightly news event.” Despite crack being the same substance as cocaine, only in a different physical form, federal criminal penalties treated 1 gram of crack as equal to 100 grams of cocaine until 2010. This caused a generation of Black and brown people to be disproportionately penalized and disenfranchised.
The punitive response to the crack epidemic is lightyears away from the compassionate, public health approach that emerged with the prescription opioid epidemic. When white middle-class users became the face of opioid addiction, attitudes towards addiction changed. Across the US, more lenient drug courts and diversion programs sprang up; prescription drug drop-off programs were set up at police stations; and police and fire departments started carrying Narcan, a drug that reverses opioid overdoses. The media response was also more compassionate. A 2017 content analysis of 100 popular press articles about the opioid epidemic notes the imbalance of media accounts about white victims of fatal overdose versus victims of color:
Generally accompanied by a picture of the lost loved one, these accounts often go into great depth about the person’s life: what s/he did in school, who his/her friends were, what s/he hoped to do in the future, what hobbies s/he enjoyed. We found no stories of overdose deaths in black and Latino communities, although we know overdose happens in those communities as well. Rather, as noted above, we found arrest stories.
In the same way the crack epidemic’s distorted narrative had devastating effects on Black and brown people, our current opioid epidemic is doubling down on that devastation. While the prescription opioid craze didn’t affect large amounts of Black Americans – because their pain was, and still is, chronically underdiagnosed and under-prescribed – the illicit fentanyl epidemic is rapidly worsening for Black and brown people. A recent study of four U.S. states found that, between 2018-2019, opioid deaths for Black people increased 38%.
And when Black people are not excluded from treatment by being disproportionately incarcerated (they are 6-10 times more likely to be sent to jail for drug offenses despite using drugs at the same rate as white people), they still face barriers accessing treatment. Racial disparities have recently been captured in the prescribing of medications that treat opioid use disorder (OUD). The two most common medications for OUD are methadone, which is heavily regulated by the DEA and is distributed at clinics that require extensive program engagement, and buprenorphine, which is simply prescribed by a doctor. You might not be surprised to hear that Black people have a harder time accessing buprenorphine. A 2021 study of this prescribing disparity notes, “Some patients even describe methadone as liquid shackles, while those transitioned from methadone to buprenorphine express feeling ‘freed’ and ‘normal again.’ This research shows that the medicalization of OUD is tiered along racial lines.”
Now that opioid prescriptions are dwindling (down more than 44% in the last decade), and the faces of the opioid epidemic are increasingly resembling Black and brown people, it will be interesting to see what happens to the “good addict/bad addict” myth, and if the newly adopted compassionate approach to addiction will hold. Unfortunately, history shows us that it does not look promising.
Over the years, I’ve heard “addiction doesn’t discriminate” more times than I can count. The problem is people do discriminate – especially people in positions of power within our social structures. They often benefit when a certain story is told a certain way. Why not blame the people they always have – the Black, brown, and poor people who chronically bear the brunt of our country’s cruelty and cowardice? Why not position them as more addicted, more depraved, and less innocent, less worthy of compassion?
When I entered recovery for my own addiction, I had to truly grapple with my emotional pain for the first time in years. I couldn’t numb-out or hide from it anymore. The United States would be a better place if our institutions could harness a sliver of the self-examination and reckoning that the average recovering person engages in each day. Truly exploring the pain behind addiction in the U.S. will break down the false “good addict/bad addict” binary in our country in a way that simply stratifying and vilifying how people numb that pain never will.
Brendan Little is the former Policy Director for Boston’s Office of Recovery Services. Find him on Twitter here.