Quána Madison is diagnosed with multiple conditions that send pain coursing through her entire body on a daily basis. Madison is also a Black woman, and medical professionals don’t always believe her.
On a hot summer day in 2017, the pain was too much to bear. Madison experienced new pain and was unable walk. She went to an emergency room in Denver, Colorado. Before the visit was over, Madison says, she was assaulted, accused of “drug-seeking” and made to fear being arrested.
MadisonAfter being diagnosed with breast cancer, Madison suffered from chronic pain for many decades. Her pain became more severe after she underwent a preventive and emergency hysterectomy. Madison was diagnosed in 2017 with several chronic pain syndromes including fibromyalgia (and peripheral neuropathy), as well as autoimmune diseases, depression and anxiety. Madison claims that she dropped out of a doctoral degree program because it did not provide accommodations. She often woke up in the middle of the nights screaming from pain.
A nurse arrived at the hospital to draw a sample of blood. Madison’s medical conditions make having blood drawn painful and, following the advice of a doctor she’d previously seen, Madison explained to the nurse that she may cry out. The nurse refused to give Madison a warm compress to help ease her pain. The nurse tried numerous times to draw blood but failed. Madison was in tears but the nurse tried again to draw blood several times and failed. Madison claims that she was frustrated and was holding her arm tightly. Madison asked for another nurse. Madison asked for another nurse. The white nurse accused Madison of exacerbating her pain to get painkillers. all-too-common experienceAmong Black people who seek medical care. Madison used her phone to record the video.
“I’ve learned as a Black woman that if I don’t record something or have a witness, I am not believed until I show the recording, and I’ve had to use that strategy multiple times to get basic care,” Madison said in an interview.
Madison began to record and the nurse reached for the phone. Alarmed, Madison’s partner, who is white, attempted to calm the nurse down. The nurse stated that she was calling police and then left. Madison was afraid she would be taken to jail when a police officer arrived. The nurse explained to the officer Madison was looking into drugs.
“All I could think of think was: I have to logically explain this step by step so I don’t get arrested. I was afraid that I would be arrested. [the officer] doesn’t believe me,” Madison said, adding that she never asked the nurse for painkillers. “I hadn’t even made it to, How can we manage my pain?”
Finally, a supervising doctor intervened and drew Madison’s blood himself. The police officer eventually left. Madison was still in severe pain and almost immobile when the officer left. Madison was advised to seek treatment elsewhere.
It wasn’t the first time Madison experienced racism in the medical system. Madison suffered extreme pain after the hysterectomy (which involves the removal of the uterus) and oophorectomy (which involve the removal and replacement of the ovaries), and was unable to get a painkiller for nearly 2 hours. Finally, Madison called a relative and asked them to call the hospital. Madison was prescribed far less painkillers than other white patients who had the same procedure. She is also routinely denied referrals for pain specialists.
Stories like Madison’s receive little attention in the media despite well-documentedRacism and bias against patients with color in the health care system, particularly Black, Latino, and Hispanic patients Indigenous patients. Years of research showsBlack (as well) Latino and Asian) patients are far less likely to receive painPatients with white skin are given more medication than patients with brown skin. systematically undertreated for painIt is often because providers wrongly believe Black people have a higher pain toleranceOr suspect they are “drug seekers” abusingSelling painkillers. This racist bias is rooted, in part, in the war against drugs that has been waged for decades against Black communities.
Black Overdose Deaths Spike
A study was published by a group of researchers at the same moment Madison’s nurse called the police. comparingThe rates of drug overdose deaths in Black and White populations are very different. The team found that painkiller prescribing was more liberal for white patients in the early 1990s due to changes in medical thinking and marketing strategies by pharmaceutical companies. However, prescribing was still low for Black patients. In 2010, the rate for fatal overdoses involving opioids had risen to twice the rate among Blacks than it was among whites. Critics of “overprescribing” concluded that discrimination had spared an estimated 14,000Black lives were saved, even though Black patients were more likely than White patients to be left in pain by racist prescribers.
However, this study does not analyze federal data. probably inaccurateIt does not tell the entire story. Overdoses are often caused by a combination drugs including alcohol. Errors on death certificates are also common. In 2018, analysts revealedThe Centers for Disease Control had attributed prescription drugs to the tens thousands of deaths caused by black market synthetics such fentanyl, and its analogues. Last year, researchers concluded the public was “misled” for more than a decade to believe that, as one White House report put it, “opiate overdoses, once almost always due to heroin use, are now increasingly due to abuse of prescription painkillers.”
Experts say that pain pills played a significant role in the crisis’ onset, particularly in whiter communities. However, rapid reductions of prescribing and availability of crushable drugs pushed users towards a volatile heroin supply. Other measures were also taken. Oxycontin, for instance, was reformulated to discourage injection drug abusers. The rates of fatal overdoses among Black and White people continued to rise after 2010.
2018 was a year when patients receiving long-term opioid therapy were struggling to get medication. or even see a doctor, many experts agreed that painkiller “overprescribing” was not causing the overdose crisis. American Medical Association declared a “multi-factorial” crisis that could no longer be viewed through “a prescription opioid-myopic lens.” Overdose death rates among Black people more than doubled over five years after 2010, researchers noted, but the increase could not be explained by the “shift” from prescription painkillers to heroin seen in white communities.
An alarming rise in death is now linked to deep racial disparities and a lopsided response in the overdose crisis. The estimated number of fatal drug overdoses in the U.S. hit a record over the past year, surpassing 100,000 deaths — roughly a 30 percentincrease in 2018-2019. Experts agree that the current approach is the best. to the crisis is not workingParticularly in communities of color.
A National Institutes of Health studyIn September, it was revealed that fatal overdoses among Blacks in four states increased 38 percent between 2018-2019. However, there was little change for whites and other groups. Overdose deaths in New York decreased by 18% for whites, but remained stable for Blacks, indicating that addiction treatment and prevention efforts did not work equally well for Black patients.
“We must explicitly examine and address how structural racism affects health and leads to drug use and overdose deaths,” concluded Nora Volkow, director of the National Institute on Drug Abuse, said in a statement.
“Whitewashing” the Overdose Crisis
Media outlets have reported on stories about young people from whiter areas who were prescribed opioids and became addicted to heroin over the past 20 years. While this is a serious problem, untreated trauma and mental illnesses have been identified as key indicators of addiction risk. However, research shows that prescriptions are not the main drivers of addiction and overdose. Today, studies show the vast majority of people prescribed opioids under medical supervision do not overdose or become addicted, and most of today’s overdose victims are not yesterday’s patients.
Media observers often made the distinction between rural and suburban whites falling prey to pain pills in the 2000s and those injecting heroin in urban areas. The death of actor Philip Seymore Hoffman in 2014 “crystalized a decade of media fascination with the white prescription opioid cum heroin user,” accordingA Drug Policy Alliance analysis from 2017. The latest story about innocent white people being conned by the pharmaceutical industry is only the beginning. “whitewashing”Issues related to opioids
The history of opioid use in the United States is not linear. There have been periodic increases in prescriptions and use, but there has been a lot of outcry and crackdowns. In the late 19th and early 20th centuries, white people who could afford medical care were considered “victims” if they became addicted to painkillers, accordingA 2020 paper co-authored with Sarah Wakeman, a Harvard professor of medicine. Access to family doctors in the 1950s and 60s allowed the upper class to shift from opioids towards sedative and stimulant drugs that had less stigma. Meanwhile, lower-income people, immigrants and people of color who informally accessed opioids for pain and other ailments were demonized and criminalized, a type of racism that escalated when President Nixon declared the “war on drugs” in 1970.
White faces were painted by lawmakers and cops to highlight the opioid scare. They started investing in treatment as an option to jail time. Anyone dependent on opioids is at risk of overdose and they began to promote a more compassionate approach to addiction. President Obama tentatively embraced a “public health” approach. While law enforcement continued to reduce opioid supply, Trump’s administration used similar rhetoric. Programs remain underfunded and inadequately funded, but criminalization continues (and has been). heightened on some frontsSome policymakers have begun to embrace harm reduction strategies, such as increasing access to medication that reverses overdoses and treating addiction. New York City recently announced the nation’s first legally sanctioned overdose prevention center, where people can use drugs under medical supervision and connect with services — a strategy proven to save lives.
Black activists saw a double standard. In the 1980s and 1990s, the media fixated on the “crack epidemic” in Black communities, and the escalating criminalization that followed filled streets with police and helped make the U.S. the most incarcerated nation on the planet. 1995 was the year that the United States had surpassed all other countries. one-thirdMany young Black men were trapped in the criminal justice system, and urban neighborhoods were seen as the epicenters for addiction. Harm reduction would not enter the mainstream conversation until authorities declared an “opioid epidemic” as the media covered prescription drug abuse in white communities.
Harm reduction and expansion of addiction treatment seemed to be beneficial. 2017 and 2018In the year 2000, overdose deaths started to decline in certain regions for first time in many years. However, overdose deaths in Black and Latinx communities continued their rise across the country. The pandemic then struck, removing people from their friends and family, as well as health supports. 2020 would be the year with the most deaths.
The new victims: Pain patients
The opioid overdose wave has prompted a police crackdown, although its nature has been somewhat different from that of the “crack era.” Law enforcement fixates on “diversion,” the idea that prescription drugs are falling into the wrong hands — perhaps drug dealers or the “opioid naïve” white people portrayed in news stories. A combination of regulation, electronic surveillance, and old-fashioned raids on pharmacies and clinics has resulted in providers being scared and put to sleep. hundreds in prisonBy contrast, the number of opioid prescriptions fell by 60 percentThe number of drug overdose deaths has more than doubled in the past decade. The outgoing Trump administration declared that the “prescription opioid epidemic” is over, but the total number of drug overdose deaths more than doubled since 2011.
Prescription pills are much safer than street drugs, as potency is measured down to the milligram, making it easier for users to know how much they’re taking. Black communities have their own pharmacies. are less likely to carry painkillersBlack patients have less options for addiction treatment and pain management than pharmacies located in whiter communities. Drug Enforcement Administration (DEA), which regulates painkiller dispensing pharmacies, has taken down or revoked licenses in many states. Black pharmacists claim that they are being unfairly targeted.
“They treated me exactly like a criminal,” said Aaron Howard, a Black pharmacist in Florida who was raided by the DEA in 2018, in an interview.
The DEA claimed Howard failed to “resolve” so-called “red flags” for diversion when a handful of patients were prescribed more than one controlled substance and chose his small pharmacy over others located closer to their homes. The DEA regularly tracks the distance between a patient’s address and the pharmacy where they fill prescriptions, according to multiple DEA search warrants reviewed by TruthoutThis surveillance is not known by most patients. Howard said he’s known the patients for years, and to his knowledge, they are still taking the medications as prescribed by their doctors.
Counterfeit prescriptions are now very common in the informal marketplace, where people who face barriers to getting health care are known as seeking relief. As police have aggressively pursued illegal heroin, traffickers have turned to potent synthetics that mimic heroin’s effects but can be transported in smaller packages. Low-level sellers may improvise in some areas. by mixing drugsWhen the supply of opioids is low, it can lead to dangerous combinations. Some drug dealers also do this. practice harm reduction to protect their clientsThey warn clients about dangerous batches and test drugs for adulterants. They also distribute safety supplies such as test strips and safety kits. Experts claim that drug sellers are a problem. an under-utilized resourceTo prevent overdose
We now know that today’s overdose crisis does not stem from prescriptions. People are dying from high doses of powerful synthetic opioids, often in combination with heroin and cocaine, as well as other drugs such as alcohol and stimulants. A Massachusetts study revealed that only 1 in 5 people have experienced withdrawal symptoms from opioids in 2019. 1.3 percentOverdose victims who had an active prescription for painkillers comprised a majority. The study was modest, but it provided the latest vindication for pain sufferers who claim they have been discriminated against and have lost access painkillers as doctors and pharmacists fear law enforcement. Some say they cannot function anymore; others commit suicide.
The “don’t punish pain” movement is growing louder as policymakers reconsider controversial limits on prescribing and courts become increasingly skepticalYou can find the myriad lawsuitsDrug manufacturers being accused of misleading advertising creating the crisis. (Other lawsuits also succeeded, including the case against Purdue Pharma for aggressively pushing Oxycontin 20 years ago. overturnLast week, the Sackler family received a $4.5 million bankruptcy settlement. Many white patients suffering from pain are now experiencing the effects of drug policing. They are angry at the lack of pain relief. These barriers have been faced by Black patients for years, according to statistics.
A Drug War Inside the Health System
There are no hard and fast rules in the overdose crisis; every drug user’s interactions (or lack thereof) with the medical and criminal legal systems are different. However, like Madison, Black and Brown people are more likely to be viewed as “addicts” or “criminals” rather than “patients.” A recent investigationIn 21 states, Black people were arrested more often for cocaine than whites for opioids in 2016. Black people were also three to four times as likely to be arrested to get all other drugs. This despite similar drug use rates across racial groups. People with low income pregnant people in particularYou may also be subject to severe stigma
The medical system is deeply entwined in the drug war. Access to buprenorphine is a drug that can be used to treat opioid addiction. It is available from pharmacies. However, there are significant racial disparities. Studies showWhite patients with private insurance are most likely to be prescribed buprenorphine as a treatment for opioid addiction. White patients with substance abuse disorders are three times more likely to be prescribed buprenorphine by a doctor than Black patients. accordingAccording to the American Medical Association. Patients of color are more likely receive methadone (the other gold standard), which is subjected to intense state surveillance.
Before the pandemic most methadone users had to come in person to receive their medication. This was a barrier for low-income persons and anyone with a hectic schedule or who doesn’t have reliable transportation. Advocates are pushing to make these changes permanent. Even though methadone patients are not subject to the same red tape as most opioid pain patients, if they were lucky enough find a provider, Methadone and buprenorphine, which are also opioids, are under constant scrutiny by police. All buprenorphine-dispensing doctors and pharmacies have been closed. There is no plan for where patients will go next. Overdose deaths are on the rise, but doctors and pharmacies remain open to treatment. are wary of prescribing and dispensing life-saving medication.
Recently, states have set up databases tracking controlled-substance prescriptions from the doctor’s office to the patient’s home address. Bamboo Health, a company formerly known as Appriss, combined Prescription Drug Monitoring Databases (PDMPs) with a plethora of personal health data to develop Narxcare, an artificial intelligence system designed to alert doctors to “drug seeking” patients and those at risk of overdose. Reporting for Wired, journalist Maia Szalavitz revealed how Narxcare’s algorithms have a “disparate impact” on women and people of color, singling out those with complex health needs and histories of trauma and even sexual abuse.
According to the algorithm, trauma places patients at greater risk of addiction. But advocates insist that AI should not be used to make prescribing decisions. Bamboo Health insists its algorithms aren’t discriminatory. Szalavitz reported that Appriss had criticized the company. controlsCriminal records data may be built intoNarxcare could be used to target people of color, who are more likely than others to be targeted by the police.
Experts disagree on the impact of prescription surveillance. Wakeman found that PDMPs are associated in some states with fewer overdoses from prescription opioids, but the increase in heroin deaths is counterbalanced by a decrease in overdoses. other researchers. PDMPs do not address the “underlying social and political forces” that contribute to addiction and overdose, Wakeman wrote, and could push patients into the illicit drug market.
“It seems to target underprovided people who don’t have access or means in this country, and just hone in on them and punish them for it,” said Bev Schechtman, a researcher with The Doctor Patient Forum who worked with Szalavitz. “These are people who don’t have a lot of access to health care to begin with.”
The policing of pain follows drug war logic: If there’s a drug problem (i.e., overdoses), then attack the supply. Advocates claim that this strategy is failing catastrophically, with Black communities suffering the most from its failures. The data shows that there was a bias against prescribing opioids for Black patients. This resulted in fewer prescriptions but did not save Black lives. Instead, Black drug users — including those with untreated pain or addiction — were quickly exposed when the supply of Oxycontin and Percocet dried up and the heroin supply became cheaper and increasingly adulterated.
Current policies are failing, harm reduction efforts will be required. a “safe supply” of opioidsPrescription heroin is also available for those at high risk for overdose.
“To address societal biases towards those with addiction, society needs to stop viewing addiction through a divided lens,” Wakeman’s team wrote. “Clinicians need to better frame addiction as a chronic illness that can affect all people, rather than as a chronic illness when it happens among socially privileged groups and a moral failing when it occurs among minorities and other marginalized groups.”
Without this necessary reframe, advocates say, the prescribing crackdown will continue to push doctors to discontinue chronic opioid therapy regardless of an individual patient’s needs — particularly in the case of Black patients and others on the margins. Patients are at risk. high risk for overdose.
“To be able to be monitored by a [doctor] … and work together, that makes it a lot easier to prevent problems, whether it be overdose or other complications,” Madison says. “But not being able to get pain management or treatment around it means that people will go to the black market, or have mental health crises that come into play.”
To combat racist practices in health care, Madison says individual providers must think carefully about their own racism and work to address it — but the work doesn’t stop there. Activists stress that health care organizations need to examine the history and invest time and resources in understanding the lived experiences of patients of color. This will take some time.
“It’s not just checking off a checklist and saying, ‘OK now we’re done,’” Madison said.
Madison believes she is fortunate to live in Colorado where medical cannabis can be legally obtained and used for pain. However, it is not as effective or as safe as opioids. Untold numbers of people are struggling with addiction and chronic pain. The overdose crisis has exploded, and the assumptions made in the past are no longer valid. Experts agree that we must confront these realities and the racism within them in order to move towards a public health approach that saves lives.