Avik Chatterjee, MD, MPH

Q: Can you briefly explain the historical racialization of addiction and addiction treatment?
A: Helena Hansen and others have laid this out well, but there is a long history in the United States of racialization in the media and in politics of depictions of those who use substances. Whether stigmatizing opioid use in Chinese Americans, associating marijuana with Mexican Americans, or heroin use with Black Americans, these media and political tropes could then be leveraged into policies that marginalized communities of color (as with the Chinese Exclusion Act, for example, or the War on Drugs).

Nixon aide John Ehrlichman famously admitted that the War on Drugs was designed to devastate Black communities politically. Even effective treatment modalities for opioid addiction, like methadone, that emerged in that era are shaped in a heavily racialized and stigmatized way (hence the nickname liquid handcuffs, indicating the carceral-influenced requirements of methadone programs).

Q: Does the public policy response to the opioid epidemic differ from the “War on Drugs,” and if so, why? How does this impact treatment among different communities?
A: As opposed to a punitive approach to addiction that conceptualizes substance use as willful criminal behavior requiring punishment, a public health approach recognizes that addiction is an illness requiring treatment.

Criminalizing possession of small amounts of drugs and incarceration with high mandatory minimum sentences for drug-related crimes did nothing to decrease overdose deaths. Rather, such policies devastated communities of color because they were typically implemented in a racist way (e.g., the 100:1 sentencing disparity for crack versus powder cocaine at a time when Black people were more likely to use crack cocaine).

A public health approach, in contrast, works to prevent the adverse effects of substance use—overdose, HIV, and hepatitis C, for example. A public health approach requires moving resources from the criminal-legal system to health care and adjacent systems—such as mental health, harm reduction, and housing support.

Unfortunately, given that many systems in the US are shaped by historical and structural racism, even the implementation of a public health approach to addiction treatment can perpetuate inequitable outcomes. For example, studies have shown that Black patients are more likely to have access to methadone and less likely to have access to buprenorphine compared to White patients. Without an equity focus, overdose prevention interventions that focus on buprenorphine alone are likely to disproportionately prevent overdose in White patients only.

Q: You had several case studies around OUD and treatment during your workshop. Why is it important to reflect on the individual, clinical, and structural levels of care for these scenarios?
A: The Social-Ecological model of health teaches us that ever-larger circles of influence—from the individual to the interpersonal, to the community, to the societal—shape health behaviors and health outcomes. Furthermore, Camara Jones’s work on levels of racism tells us that racism works at the internalized, interpersonal, and institutional levels. Thus, interventions solely aimed at individuals, or even at the clinic level, could never successfully make outcomes for large numbers of people more equitable.

Q: How are minoritized women, specifically, affected by SUD treatment and outcomes?
A: One specific way is the way in which substance use and treatment are particularly stigmatized in people who are pregnant or caring for children. Healthcare providers are more likely to drug test pregnant patients of color. This leads to disproportionate involvement of child protective services in families of color and subsequent trauma to children and caregivers. Furthermore, even in otherwise progressive states like Massachusetts, pregnant patients receiving prescribed medications for opioid use disorder are mandated to have a Department of Children and Families referral, regardless of how long they have been clinically stable on medications. This can actually serve as a deterrent to starting medications, increasing the risk of overdose and adverse pregnancy outcomes, particularly in mothers of color

Q: How can SGIM members get involved in combating racialized treatment of addiction?
A: First, get buprenorphine waivered so you can prescribe it for all your patients, and if your practice is not already doing so, transform your practice so it offers buprenorphine.

Second, advocate in your community for the expansion of access to MOUD under existing laws. For example, push for more methadone programs, mobile buprenorphine, and methadone programs, and MOUD programs in innovative settings such as shelters, correctional facilities, churches, and barber shops.

Finally, work to change existing laws to decrease the punitive approach to substance use in favor of a public health approach. Support efforts to decriminalize substance possession and use. Support efforts to expand harm reduction offerings, including syringe exchange programs in states that don’t have them, and safe consumption sites. Existing policies must change for our approach to substance use to become more equitable.