CPSolvers: Anti-Racism in Medicine Series
Episode 19 – Reframing the Opioid Epidemic: Anti-Racist Praxis, Racial Health Inequities, and Harm Reduction
Show Notes by Alec Calac
February 9, 2022
Summary: This episode highlights racialized disparities in addiction treatment. During this episode, we hear from Dr. Jessica Isom, a board-certified community psychiatrist and faculty leader in the Yale Department of Psychiatry’s Social Justice and Health Equity Curriculum, and Dr. Ayana Jordan, the endowed Barbara Wilson Associate Professor in the Department of Psychiatry, Addiction Psychiatrist and Associate Professor in the Department of Population Health at New York University (NYU) Grossman School of Medicine. Together, our guests explore and unpack how the criminalization and racialization of substance use builds to the present-day opioid epidemic and shapes inequities in care. There is a special emphasis on the use of public health models that prioritize harm reduction and person-centered care to prevent drug-related fatalities and curb the opioid epidemic along lines of race and class. This discussion is hosted by Ashley Cooper, Sudarshan Krishnamurthy, and new team member Gillette Pierce.
Episode Learning Objectives:
After listening to this episode, learners will be able to…
- Explain how the criminalization and racialization of substance use builds to the present-day opioid epidemic and shapes inequities in care.
- Describe how the media shapes public sentiment toward substance use and addiction treatment.
- Identify realistic solutions to drug policy reform that promote health equity among marginalized communities living in the United States.
- Written and produced by: Ashley Cooper, MPhil; Sudarshan Krishnamurthy; Gillette Pierce; Alec J. Calac; Michelle Ogunwole, MD, PhD; Ayana Watkins; Chioma Onuoha; Naomi F. Fields, MD; Victor A. Lopez-Carmen, MPH; Rohan Khazanchi, MPH; Sudarshan Krishnamurthy; Utibe R. Essien, MD, MPH; Jazzmin Williams; LaShyra Nolen; Jennifer Tsai MD, MEd
- Hosts: Ashley Cooper, Sudarshan Krishnamurthy, and Gillette Pierce
- Infographic: Creative Edge Design
- Audio Edits: Caroline Cao and Ashley Cooper, MPhil
- Show Notes: Alec Calac
- Guests: Jessica Isom, MD, MPH and Ayana Jordan, MD, PhD
1:30 Guest Introductions
4:15 Framing the Sociohistorical Context of the Opioid Epidemic
10:47 Racialization of Substance Use and Medicalization of the Human Experience
14:28 Changing “Faces of Addiction” and Impact on U.S. Drug Policy
16:35 United States, Chinese Laborers, and Anti-Chinese Sentiment (“Opium Fiends”)
19:30 “Moral Panic”
23:00 Separating Minoritized Individuals from the Majority
23:40 Cocaine Possession Sentencing Disparities
26:50 Shifting Social Attitudes Toward Substance Use and Addiction
30:30 (Mis)framing of Substance Use as a White Problem to Enact Change
33:15 Rectifying Racial Health Inequities in Opioid Addiction Treatment
36:10 Take-Home Methadone and a Less Clear Need for Methadone Clinics
40:40 Understanding Substance Use Disparities with Racially Disaggregated Data
47:00 Pushing Back Against “One Size Fits Most”
49:30 Harm Reduction Practices
53:00 Narrowing the Empathy Gap and Connecting with Patients
55:25 Spirit of Sankofa: Looking Back to Move Forward
59:15 Reducing Harm and “Optimizing Safety”
1:08:00 Community-Centered Solutions
1:10:20 Drug Policy Reform
1:15:42 Episode Takeaways
- Health care providers, especially physicians, cannot be equity-ignorant or egalitarian in our racialized society. They can use their training and privilege to advocate for meaningful policy reform.
- The opioid epidemic is more than a white problem. Demographic data in research and practice must always be disaggregated by race and ethnicity.
- Screening for substance use and offering connections to treatment and community-based services are important strategies that clinicians can implement in their own practice today.
- In 2020, American Indian and Alaska Native (Indigenous) communities experienced the highest drug overdose mortality rate of any racial or ethnic group, also surpassing rates among the non-Hispanic white population. Between 2007 – 2019, Black individuals experienced a higher death rate for opioid overdose deaths than any other racial or ethnic group. [Supplementary Resource for Listeners: CPSolvers Episode 12: Addressing Anti-Indigenous Racism in Medicine with team members Alec Calac and Victor Anthony Lopez-Carmen]
- Dr. Jordan begins our episode by framing the racialization and criminalization of substance use in the larger history of the United States, emphasizing that American society has seen substance use as “criminal behavior” or a moral failing, rather than as a medical condition, which began towards the early 2000s. She mentions that academia, as well as the media, have contributed to this complex social phenomenon by tying together race, gender, and substance use, especially in the context of maternal health and neonatal abstinence syndrome. The foundational literature in this area has furthered stigma and bias, especially towards Black birthing persons. These narratives have vilified individuals who would benefit from comprehensive, person-centered substance use treatment, rather than incarceration and other adverse harms.
- Dr. Isom continues the conversation around the intentionality of these structural processes and the language that frames the racialization of substance use in the United States by lawmakers, media, and the healthcare profession. This parallels another process, which is the medicalization of human experiences, especially those relating to childbirth and pregnancy. A more Western perspective on health care emphasizes the role of physicians and health care providers and marginalizes the role and contributions of doulas and midwives. She then ties this back to Dr. Jordan’s conversation about the criminalization of substance use and how resources and infrastructure are dedicated to incarceration, rather than psychotherapy and related treatments. [Supplementary Resource for Listeners: Advancing Health Equity: A Guide to Language, Narrative and Concepts]
- Sudarshan goes further into the changing “faces of addiction” and asks our guests to describe its impact on drug policy in the United States. Dr. Isom first challenges our listeners to engage with anti-racist praxis and challenge dominant racial narratives about substance use, policing, and other encounters. She then goes into how the racialization of substance use drove positive public sentiment for the adoption of punitive outcomes for substance use. One example that is presented involves the complicated relationship between the United States and Chinese immigrants and farmworkers in California. Once the need for labor was largely met, anti-Chinese narratives (e.g., opium fiends) emerged around opium, gambling, and prostitution, which fits into this pattern or formula of associating specific racial and ethnic groups with substance use as a rhetorical threat to the “most valued demographic” in the United States (white women and children) to drive the adoption of punitive measures. This largely obscures the reality that substance use rates are similar among different racial and ethnic groups. [Supplementary Resource for Listeners: San Francisco Opium Ordinance described in Race and the Criminalization of Drugs – National Press Foundation | NPF featuring Dr. Jessica Isom and Dr. Helena Hansen]
- Dr. Jordan echoes these thoughts and posits that divergence from the “ideal” American identity (i.e., white, cisgender, heterosexual) makes it possible to other (verb) individuals and enact policies and laws that punish individuals with marginalized identities. She shared that rhetoric used by Nixon and the subsequent war on drugs has similarities to Trumpism and messaging associated with Make America Great Again (MAGA). This is then reaffirmed during the Reagan Administration and is later codified into sentencing structures, in which we see vastly different amounts of cocaine possession (100:1 crack versus powder cocaine possession offenses) amounting to similar sentences, with crack cocaine use most prevalent among minoritized individuals and powder cocaine use most prevalent among the white majority. Involvement with the carceral system further intersects with issues around employment, household income, and other related disparities. To our listeners, how might we begin redressing these harms and reinvest in minority communities adversely affected by the war on drugs? [Supplementary Resource for Listeners: Cracks in the System: 20 Years of the Unjust Federal Crack Cocaine Law | American Civil Liberties Union]
- The conversation then shifts into changing social attitudes toward substance use and addiction. Dr. Isom breaks down media messaging and the varying tones and contexts used to describe substance use disparities and how that contributes to social stigma. She explains how different types of stigma intersect with media messaging to craft narratives that encourage sympathy or even a lack of sympathy towards certain racial and ethnic groups and health behaviors. Dr. Isom then discusses that policy reform and changing attitudes toward substance use and addiction are largely driven by the hurt and pain of those in the white majority with substance use disorder, further minimizing the experiences of marginalized communities.
- Dr. Jordan agrees with this characterization and goes more into the historical media coverage of substance use and the dehumanizing language that was (and is still) used to describe drug use among minority individuals. This segues into a conversation about the legacy of the war on drugs and today’s racial inequities in opioid addiction treatment. Ashley delineates that methadone has been disproportionately prescribed in predominantly Black communities, as a means to drive down crime, whereas white patients undergoing substance use treatment are more likely to receive buprenorphine. Dr. Jordan highlights the harm that these prescribing practices cause as they falsely associate race and substance use with criminal activity and neighborhood safety. She further goes into the stigma and stereotyping that continues to this day with the incessant and inhumane need to pick up prescription treatment once daily, submit “clean” urine samples under direct supervision, and submit to oral examinations. Dr. Jordan then questions the utility and continued operation of methadone clinics, especially as the United States largely moves on from the COVID-19 pandemic. She highlights actions taken by the United States Substance Abuse and Mental Health Services Administration (SAMHSA) to expand access to take-home methadone doses, which promoted patient autonomy and had comparable adherences outcomes and no significant changes in potential adverse harms, such as overdose and diversion. Other actions include elimination of the United States Drug Enforcement Administration (DEA) X waiver which was needed to prescribe buprenorphine. Dr. Jordan concludes by thinking about incentive strategies that would encourage health care providers to change their prescribing practices and minimize racial inequities in opioid addiction treatment [Supplementary Resource for Listeners: Lessons from COVID 19: Are we finally ready to make opioid treatment accessible? – PMC]
- Dr. Isom highlights the differences in substance use disparities and infrastructure utilization from the national level moving into discrete communities. Using an equity lens, she shares her own experiences in Massachusetts examining treatment utilization and encourages health care providers to examine racially disaggregated data to make sure that services offering suboxone (buprenorphine and naloxone) are reaching and being used in the most impacted communities. She also discusses the importance of the patient-provider relationship and shared-decision making, which helps ensure that a full range of services are being offered to patients. Dr. Jordan and Dr. Isom both agree that simply offering treatment services and having an “open door” are not enough. Dr. Jordan discusses the importance of de-centering the majority and identifying the factors that are most relevant to minoritized individuals and communities. Oftentimes, researchers and practitioners working to implement addiction treatment programs and interventions are not from those same communities. Dr. Jordan pushes back on the notion that “one size fits most” is the optimal approach for treating substance use disorder and that the evidence we rely on for patients undergoing substance use treatment was largely informed by the experiences of white individuals. Therefore, traditional settings of addiction care may unintentionally cause harm to individuals with marginalized identities.
- Gillette moves the conversation into strategies addressing substance use disparities, particularly those that emphasize the importance of harm reduction. Dr. Isom begins by sharing her experiences in the clinic and how harm reduction approaches such as offering fentanyl test strips humanize substance use treatment and place individual and community health and well-being at the center of treatment. To her dismay, she also learned that her racially and linguistically diverse patient population was one of most affected by the opioid epidemic in the Commonwealth of Massachusetts. Reflecting on these health data and rethinking “traditional” addiction treatment strategies helped her connect with her patients and close a self-described empathy gap that she says patients accessing treatment often have with their health care provider. Dr. Jordan enters into the conversation and also shares how she best connects with her patients who often feel unheard and marginalized by the health care system. She discusses the strengths and limitations of harm reduction approaches and the continued need for a clinician-researcher workforce that reflects the diversity seen in communities experiencing hardship. An important part of her discussion includes the contributions of community health workers and a need not just to focus on harm reduction, but also to optimize safety among individuals using substances such as alcohol and opioids. This complementary approach has the potential to increase the positive impact that the harm reduction movement has made over time.
- The group briefly discusses Dr. Isom’s article Nothing About Us Without Us in Policy Creation and Implementation | Psychiatric Services (2021) which highlights the need for patients and communities to be included in the creation and implementation of drug policy. This approach has the potential to best direct resources to the most impacted communities and may be more impactful than traditional community engagement models. Dr. Jordan has also written about culturally-responsive programs benefiting Black communities affected by the opioid epidemic and has completed a pilot study providing addiction treatment in partnership with faith-based organizations. Both guests acknowledge that academics do not always have the right solutions and that practitioners have to listen openly to community knowledge holders.
- Towards the end of the episode, Dr. Jordan highlights opportunities for meaningful drug policy reform, including examining federal methadone regulations (e.g., dosing, availability), investing in harm reduction and safety optimization, and decreasing police involvement in mental health crisis response and police presence in substance use treatment settings.
New Host! Kiersten TâLeigh (Ta-Lee) “Gillette” Gillette-Pierce (she/they) is currently a student at Johns Hopkins School of Public Health pursuing a Master of Science in Public Health with a double concentration in Maternal, Fetal, and Perinatal Health and Women, Sexual and Reproductive Health. As an academic researcher, they focus on transnational racial/ethnic and gender disparities in pregnancy-related, sexual, and reproductive health outcomes for all persons with gynecologic organs, with a specific interest in people of African descent. She is published in the Journal of Advanced Nursing and Medicine, Science, and Law. Gillette has also published work with Rewire News Group and the Center for American Progress focusing on sexual and reproductive health and rights policy, reproductive justice, and health outcomes for Black birthing persons. With almost ten years of experience in the global sexual and reproductive health, rights, and justice field, Gillette aims to improve sexual and reproductive health care and outcomes for disenfranchised communities and significantly improve pregnancy-related outcomes for people of African descent.
Dr. Jessica Isom, MD, MPH, is a board-certified community psychiatrist and faculty leader in the Yale Department of Psychiatry’s Social Justice and Health Equity Curriculum. She primarily works in Boston as an attending psychiatrist at Codman Square Health Center where she is leading a grant effort to infuse antiracism in Opioid Use Disorder (OUD) services. She is a nationally recognized expert on racial equity and justice in psychiatry with a focus on workforce development and organizational transformation. Her professional interests include working toward eradicating racial and ethnic mental health disparities, mitigating the impact of implicit racial bias on clinical care, and the use of a community-centered population health approach in psychiatric practice. She serves on multiple advisory boards and is a consultant, curriculum developer and presenter to a variety of organizations including Fortune 500 companies and medical societies through her company, Vision for Equity LLC. Dr. Isom received her MD from the University of North Carolina School of Medicine, and completed her residency at Yale University.
Ayana Jordan, MD, PhD, is the Barbara Wilson Associate Professor in the Department of Psychiatry, Addiction Psychiatrist and Associate Professor in the Department of Population Health at New York University (NYU) Grossman School of Medicine. She also serves as Pillar Co-Lead for Community Engagement at NYU Langone’s Institute for Excellence in Health Equity. As Principal Investigator for the Jordan Wellness Collaborative (JWC), she leads a research, education, and clinical program that partners with community members to provide optimal access to evidence-based treatments for racial and ethnic minoritized patients with mental health disorders. Through her multifaceted work, she provides addiction treatment in faith settings, studies health outcomes for people with opioid use disorder in the carceral system, and trains addiction specialists to provide culturally-informed treatment. Dr. Jordan is dedicated to creating spaces and opportunities for more people of color, specifically Black women in academia who are vastly underrepresented. She has numerous peer-reviewed publications, has been featured at international conferences, and is the proud recipient of various clinical and research awards. The fundamental message of equity and inclusion has informed her research, clinical work, and leadership duties at NYU and beyond.
- Ahmad FB, Cisewski JA, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. 2022. Designed by LM Rossen, A Lipphardt, FB Ahmad, JM Keralis, and Y Chong: National Center for Health Statistics.
- American Medical Association; Manatt Health. National roadmap on state-level efforts to end the opioid epidemic: leading-edge practices and next steps. https://www.end-opioid-epidemic.org/wp-content/uploads/2019/09/AMA-Manatt-National-Roadmap-September-2019-FINAL.pdf. Published September 2019. Accessed October 17, 2022.
- Balasuriya, L., Isom, J., Cyrus, K., Ali, H., Sloan, A., Arnaout, B., Steinfeld, M., DeSouza, F., Jordan, A., Encandela, J., & Rohrbaugh, R. (2021). The Time Is Now: Teaching Psychiatry Residents to Understand and Respond to Oppression through the Development of the Human Experience Track. Academic Psychiatry, 45(1), 78–83. https://doi.org/10.1007/s40596-021-01399-x
- Castillo, E. G., Isom, J., DeBonis, K. L., Jordan, A., Braslow, J. T., & Rohrbaugh, R. (2020). Reconsidering Systems-Based Practice: Advancing Structural Competency, Health Equity, and Social Responsibility in Graduate Medical Education. Academic Medicine, 95(12), 1817–1822. https://doi.org/10.1097/ACM.0000000000003559
- DeSouza, F., Mathis, M., Lastra, N., & Isom, J. (2021). Navigating Race in the Psychotherapeutic Encounter: A Call for Supervision. Academic Psychiatry, 45(1), 132–133. https://doi.org/10.1007/s40596-020-01328-4
- Friedman, J. R., & Hansen, H. (2022). Evaluation of Increases in Drug Overdose Mortality Rates in the US by Race and Ethnicity Before and During the COVID-19 Pandemic. JAMA Psychiatry, 79(4), 379. https://doi.org/10.1001/jamapsychiatry.2022.0004
- Godkhindi P, Nussey L, O’Shea T. “They’re causing more harm than good”: a qualitative study exploring racism in harm reduction through the experiences of racialized people who use drugs. Harm Reduct J. 2022 Aug 25;19(1):96. doi: 10.1186/s12954-022-00672-y. PMID: 36008816; PMCID: PMC9406271.
- Goldman, M. L., Swartz, M. S., Norquist, G. S., Horvitz-Lennon, M., Balasuriya, L., Jorgensen, S., Greiner, M., Brinkley, A., Hayes, H., Isom, J., Dixon, L. B., & Druss, B. G. (2022). Building Bridges Between Evidence and Policy in Mental Health Services Research: Introducing the Policy Review Article Type. Psychiatric Services, 73(10), 1165–1168. https://doi.org/10.1176/appi.ps.202100428
- Hansen H, Jordan A, Plough A, Alegria M, Cunningham C, Ostrovsky A. Lessons for the Opioid Crisis-Integrating Social Determinants of Health Into Clinical Care. Am J Public Health. 2022 Apr;112(S2):S109-S111. doi: 10.2105/AJPH.2021.306651. PMID: 35349328; PMCID: PMC8965192.
- Hughes M, Suhail-Sindhu S, Namirembe S, Jordan A, Medlock M, Tookes HE, Turner J, Gonzalez-Zuniga P. The Crucial Role of Black, Latinx, and Indigenous Leadership in Harm Reduction and Addiction Treatment. Am J Public Health. 2022 Apr;112(S2):S136-S139. doi: 10.2105/AJPH.2022.306807. PMID: 35349317; PMCID: PMC8965189.
- Isom, J., & Balasuriya, L. (2021). Nothing About Us Without Us in Policy Creation and Implementation. Psychiatric Services, 72(2), 121–121. https://doi.org/10.1176/appi.ps.72202
- Isom, J., Jordan, A., Goodsmith, N., Medlock, M. M., DeSouza, F., Shadravan, S. M., Halbert, E., Hairston, D., Castillo, E., & Rohrbaugh, R. (2021). Equity in Progress: Development of Health Equity Curricula in Three Psychiatry Residency Programs. Academic Psychiatry, 45(1), 54–60. https://doi.org/10.1007/s40596-020-01390-y
- James K, Jordan A. The Opioid Crisis in Black Communities. J Law Med Ethics. 2018 Jun;46(2):404-421. doi: 10.1177/1073110518782949. PMID: 30146996.
- Jordan, A., Mathis, M. L., & Isom, J. (2020). Achieving Mental Health Equity: Addictions. Psychiatric Clinics of North America, 43(3), 487–500. https://doi.org/10.1016/j.psc.2020.05.007
- Jordan A, Babuscio T, Nich C, Carroll KM. A feasibility study providing substance use treatment in the Black church. J Subst Abuse Treat. 2021 May;124:108218. doi: 10.1016/j.jsat.2020.108218. Epub 2020 Dec 3. PMID: 33771290.
- Kuehn, B. M. (2022). Black Individuals Are Hardest Hit by Drug Overdose Death Increases. JAMA, 328(8), 702. https://doi.org/10.1001/jama.2022.13702
- Lagisetty, P. A., Ross, R., Bohnert, A., Clay, M., & Maust, D. T. (2019). Buprenorphine Treatment Divide by Race/Ethnicity and Payment. JAMA Psychiatry, 76(9), 979. https://doi.org/10.1001/jamapsychiatry.2019.0876
- Naseem S. Miller. (2021, May 17). Racial disparities in opioid addiction treatment: Primer & research roundup. The Journalist’s Resource. https://journalistsresource.org/home/systemic-racism-opioid-addiction-treatment/
- Nweke, N., Isom, J., & Fashaw-Walters, S. (2022). Health Equity Tourism: Reckoning with Medical Mistrust. Journal of Medical Systems, 46(5), 27. https://doi.org/10.1007/s10916-022-01812-4
- Portnoy, G. A., Doran, J. M., Isom, J. E., Wilkins, K. M., DeViva, J. C., & Stacy, M. A. (2021). An evidence-based path forward for diversity training in medicine. The Lancet Psychiatry, 8(3), 181–182. https://doi.org/10.1016/S2215-0366(21)00024-9
- Race and the Criminalization of Drugs. (2021, April 22). National Press Foundation. https://nationalpress.org/topic/race-and-the-criminalization-of-drugs/
- Roxas, N., Ahuja, C., Isom, J., Wilkinson, S. T., & Capurso, N. (2021). A Potential Case of Acute Ketamine Withdrawal: Clinical Implications for the Treatment of Refractory Depression. American Journal of Psychiatry, 178(7), 588–591. https://doi.org/10.1176/appi.ajp.2020.20101480
- Townsend, T., Kline, D., Rivera-Aguirre, A., Bunting, A. M., Mauro, P. M., Marshall, B. D. L., Martins, S. S., & Cerdá, M. (2022). Racial/Ethnic and Geographic Trends in Combined Stimulant/Opioid Overdoses, 2007–2019. American Journal of Epidemiology, 191(4), 599–612. https://doi.org/10.1093/aje/kwab290
- Wyatt JP, Suen LW, Coe WH, Adams ZM, Gandhi M, Batchelor HM, Castellanos S, Joshi N, Satterwhite S, Pérez-Rodríguez R, Rodríguez-Guerra E, Albizu-Garcia CE, Knight KR, Jordan A. Federal and State Regulatory Changes to Methadone Take-Home Doses: Impact of Sociostructural Factors. Am J Public Health. 2022 Apr;112(S2):S143-S146. doi: 10.2105/AJPH.2022.306806. PMID: 35349318; PMCID: PMC8965186.
The hosts and guests report no relevant financial disclosures.
Isom J, Jordan A, Cooper A, Krishnamurthy S, Pierce G, Calac A, Watkins A, Onuoha C, Lopez-Carmen VA, Nolen L, Williams J, Tsai J, Ogunwole M, Khazanchi R, Fields NF. “Episode 19: Reframing the Opioid Epidemic: Anti-Racist Praxis, Racial Health Inequities, and Harm Reduction”. The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://