The opioid crisis is neither a white person nor an adult’s problem

How Can Psychiatrists Improve Drug Addiction Treatment in Black and Pediatric Patients?

The high-profile death of 54-year-old actor Michael K. Williams confirmed to be due to an overdose of heroin, cocaine and fentanyl,1 was a sobering reminder that the opioid crisis is far from a problem limited to white Americans, although it has often been described as such.2

Williams has spoken openly about her own struggles with substance abuse, and celebrities revealing mental illness can be a powerful method of increasing help-seeking behaviors, especially for minority communities.3.4 In addition, he has been heavily involved in community work for children, founding Making Kids Win, a charity that creates community centers to provide safe places for children to play and learn. Williams himself suffered significant trauma as a child and admitted he started using substances as a teenager to heal himself.5 In fact, studies have shown that most adults with substance use disorders (SUD) start using substances before the age of 18.6 If psychiatrists are to tackle the opioid epidemic, they must understand the needs of often neglected communities and start early, in childhood and adolescence.

Neglected and in danger

I recently attended a conference on the effects of maternal opioid use on newborns. The presenter showed slides depicting mothers with opioid use disorder (OUD) through a humanizing rather than criminalizing lens. All of these mothers were white. This was a particularly disturbing coincidence, given the racialization of drug use and the racist pattern in the media – the favorable portrayal of white opioid users in rural and suburban areas versus the unfavorable portrayal of white opioid users in rural and suburban areas. black opioid users living in urban communities.7 Black Americans with DU are too often portrayed as poor, urban criminals injecting opioids. This is a racially inaccurate portrayal in itself, given that black people with DUs also live in suburbs and rural areas.

In 2017, the US Department of Health and Human Services declared the opioid epidemic a public health emergency after witnessing the monumental number of opioid overdose deaths.8 From then until 2019, although white deaths are on the decline, opioid overdose deaths among black Americans, and particularly black men, have increased.9 Synthetic opioids have hit black communities disproportionately. From 2011 to 2016, black Americans experienced the largest increase in opioid death rates due to synthetic opioids, such as fentanyl,ten and from 2016 to 2017, black Americans experienced a 61% increase in fatal synthetic opioid overdoses, compared with a 45% increase in white Americans.11

Current interventions used for OUDs, and arguably SUDs in general, do not work optimally for everyone. Certainly, white individuals have been affected by the opioid crisis and, before the onset of fentanyl, they had the highest rates and number of opioid overdose deaths.9 However, the opioid crisis is not just hurting whites, and blacks are often left behind when it comes to OUD interventions.

One size won’t fit all

Treatment interventions for TOU should not be the same for all populations, as not all populations are treated the same when it comes to TOU. The racist war on drugs, which disproportionately targeted black populations,12 is just one example. Black people are disproportionately criminalized for SUD, making it more difficult for them to trust and therefore access drug treatment. Although white individuals are more likely to sell drugs than black individuals, black individuals are more likely to be arrested for doing so.13 Black Americans are also more likely to be arrested for drug possession, even though whites and blacks use substances at similar rates.

Racial disparities even exist in the distribution of psychopharmacological treatment for DUs.9 There is different access to buprenorphine and methadone, the former being less likely to be available in black communities than the latter. Methadone requires daily appointments, while buprenorphine is a pill to go. In essence, the most convenient treatment is less accessible to blacks. OUD interventions need to do more to specifically target black communities, and the ads and slides for OUD interventions that feature uniquely white families misrepresent the true demographics of the epidemic. Black patients need to be reassured that their SUD will be humanized and treated as psychiatric disorders, not punishable crimes.

Children in the epidemic

During the opioid crisis, less attention was paid to the impact of OUD on children and adolescents. Although a myriad of research studies exist on the impact of OUDs on newborns, children one year of age or older receive less attention when it comes to OUD research, with only 2% of funding. federal drug addiction research focusing on children or families.14 Beyond research, there is a need for clinical training on navigation in TOU in children and adolescents, and in addition, to help prevent them. Children and adolescents of parents with TOU should be given advance counseling about opioid use, including support to understand why they may be at higher risk for developing TOU.

Granted, child and adolescent psychiatrists have these kinds of conversations with their individual patients all the time, but these conversations (or not) are often left to the psychiatrist’s discretion, rather than making them a standard of care. As a resident in adult / child psychiatry, I received most of my SOUTH training from my time with adults, rather than children.

Concluding thoughts

While we are certainly trained to ask questions about SUD in children and to monitor and treat them once they occur, what about preventing them? Perhaps neonates who suffer from neonatal abstinence syndrome should be flagged for SUD preventive care when they reach a certain age, although the long-term psychiatric outcomes of neonates exposed to opioids in utero are still a hotly debated subject.15 Perhaps children who are exposed to trauma should be counseled on the risk of substance use, among risky behaviors, to try to cope, especially if these children are already seen by a child and adolescent psychiatrist for other reasons. One thing is certain, the opioid crisis is far from being a problem for whites or adults, for that matter. And unfortunately, it is far from over.

Dr Calhoun is a resident in Adult / Child Psychiatry at the Yale Child Study Center / Yale School of Medicine. She is also a Public Voices member of the OpEd project at Yale University.

The references

1. Gold M, Bromwich JE. Michael K. Williams died of a drug overdose, authorities said. New York Times. September 27, 2021. Accessed September 26, 2021.

2. Shihipar A. The opioid crisis is not white. New York Times. February 26, 2019. Accessed September 26, 2021.

3. Calhoun AJ, Gold JA. “I feel like I know them”: the positive effect of celebrity self-disclosure of mental illness. Acad Psychiatry. 2020; 44 (2): 237-241.

4. Murray E. Michael K. Williams has never hidden his addiction issues. Addiction Center. September 9, 2021. Accessed September 30, 2021.

5. Jackson D. Everything Michael K. Williams Has Said About Addiction And Its Mental Health Problems. People magazine. September 24, 2021. Accessed September 26, 2021.

6. National Institute on Drug Abuse. Principles of Treatment for Substance Use Disorders in Adolescents: A Research-Based Guide. Revised January 2014. Accessed September 30, 2021.

7. Netherlands J, Hansen HB. The war on drugs that wasn’t: wasted whiteness, “dirty doctors” and the race for media coverage of prescription opioid abuse. Worship Med Psychiatry. 2016; 40 (4): 664-686.

8. US Department of Health and Human Services. HHS Acting Secretary declares a public health emergency to address the national opioid crisis. October 26, 2017. Accessed September 26, 2021.

9. White C. Progress against the opioid epidemic is not reaching black Americans. City of Health. February 8, 2021. Accessed September 26, 2021.

10. Agency for Research and Quality of Health Care. Blacks are experiencing a rapid increase in overdose death rates involving synthetic opioids other than methadone. February 2020. Accessed September 26, 2021.

11. Goodnough A. In the cities where she once ruled, heroin is disappearing. New York Times. May 18, 2019. Accessed September 26, 2021.

12. United States Sentencing Commission. 2015 Report to Congress: Impact of the Fair Sentences Act 2010. 2015. Accessed September 26, 2021.

13. Ingraham C. Whites are more likely to sell drugs, but blacks are more likely to be arrested for it. The Washington Post. September 30, 2014. Accessed September 30, 2021.

14. Winstanley EL, Stover AN. The impact of the opioid epidemic on children and adolescents. Clin Ther. 2019; 41 (9): 1655-1662.

15. Larson JJ, Graham DL, Singer LT, et al. Cognitive and behavioral impact on children exposed to opioids during pregnancy. Pediatrics. 2019; 144 (2): e20190514.

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