Abstract
The COVID-19 pandemic has highlighted the large racial health disparities in the United States. Black Americans have experienced worse outcomes during the pandemic, continue to die at a greater rate than White Americans, and also suffer disproportionately from a wide range of other acute and chronic illnesses. These disparities are particularly stark in the field of substance use and substance use disorders, where entrenched punitive approaches have exacerbated stigma and made it hard to implement appropriate medical care. Abundant data show that Black people and other communities of color have been disproportionately harmed by decades of addressing drug use as a crime rather than as a matter of public health [1]. We have known for decades that addiction is a medical condition—a treatable brain disorder—not a character flaw or a form of social deviance. Yet, despite the overwhelming evidence supporting that position, drug addiction continues to be criminalized. The USA must take a public health approach to drug addiction now, in the interest of both population well-being and health equity.
Inequitable enforcement
Although statistics vary by drug type, overall, White and Black people do not significantly differ in their use of drugs, yet the legal consequences they face are often very different. Even though they use cannabis at similar rates, for instance, Black people were nearly four times more likely to be arrested for cannabis possession than White people in 2018 [2]. Of the 277,000 people imprisoned nationwide for a drug offense in 2013, more than half (56%) were African American or Latino even though together those groups accounted for about a quarter of the US population [3].
During the early years of the opioid crisis in this century, arrests for heroin greatly exceeded those for diverted prescription opioids, even though the latter—which were predominantly used by White people—were more widely misused [4]. It is well known that during the crack cocaine epidemic in the 1980s, much harsher penalties were imposed for crack (or freebase) cocaine, which had high rates of use in urban communities of color, than for powder cocaine, even though they are two forms of the same drug [5,6,7]. These are just a few examples of the kinds of racial discrimination that have long been associated with drug laws and their policing [8].
Ineffective punishment
Drug use continues to be penalized, despite the fact that punishment does not ameliorate substance use disorders or related problems. One analysis by the Pew Charitable Trusts found no statistically significant relationship between state drug imprisonment rates and three indicators of state drug problems: self-reported drug use, drug overdose deaths, and drug arrests [9].
Imprisonment, whether for drug or other offenses, actually leads to much higher risk of drug overdose upon release [10]. More than half of people in prison have an untreated substance use disorder [11], and illicit drug and medication use typically greatly increases following a period of imprisonment [12]. When it involves an untreated opioid use disorder, relapse to drug use can be fatal due to loss of opioid tolerance that may have occurred while the person was incarcerated.
Inequitable access to treatment
While the opioid crisis has triggered some efforts to move away from punishment toward addressing addiction as a matter of public health, the application of a public health strategy to drug misuse remains unevenly distributed by race/ethnicity [13]. Compared to White people, Black and Hispanic people are more likely to be imprisoned after drug arrests than to be diverted into treatment programs [14].
Also, a 2018 study in Florida found that African Americans seeking addiction treatment experienced significant delays entering treatment (4–5 years) compared to Whites, leading to greater progression of substance use disorders, poorer treatment outcomes, and increased rates of overdose [15]. These delays could not be attributed to socioeconomic status alone. Studies have shown that Black youth with opioid use disorder are significantly less likely than White peers to be prescribed medication treatment (42% less likely in one study [16], 49% in another [17]) and that Black patients with opioid use disorder are 77% less likely than White patients to receive the opioid addiction medication buprenorphine [18].
A vicious cycle of punishment
The damaging impacts of punishment for drug possession that disproportionately impact Black lives are wide ranging. Imprisonment leads to isolation, an exacerbating factor for drug misuse, addiction, and relapse. It also raises the risk of early death from a wide variety of causes [19].
Besides leading to incarceration, an arrest for possession of even a small amount of cannabis—a much more common outcome for Black youth than White youth [20]—can leave the individual with a criminal record that severely limits their future opportunities such as higher education and employment [21]. This excess burden of felony drug convictions and imprisonment has radiating impacts on Black children and families. Parents who are arrested can lose custody of their children, entering the latter into the child welfare system. According to another analysis by the Pew Charitable Trusts, one in nine African American children (11.4%) and 1 in 28 Hispanic children (3.5%) have an incarcerated parent, compared to 1 in 57 White children (1.8%) [22].
This burden reinforces poverty by limiting upward mobility through impeded access to employment, housing, higher education, and eligibility to vote. It also harms the health of the incarcerated, their non-incarcerated family members, and their communities [23].
Moving toward a public health approach
Five years ago, the 193 member nations of the United Nations General Assembly Special Session on drugs unanimously voted to recognize the need to approach substance use disorders as public health issues rather than punishing them as criminal offenses [24]. Public health-based alternatives to criminalization range from drug courts and other diversion programs to policies decriminalizing drug possession.
How best to move away from punishing drug use is an important question, and it might require diverse strategies. There is a wide spectrum of potential models of decriminalization, and some of these models are already being implemented in various US states and localities as well as in other countries [25]. Research is urgently needed to establish the effectiveness and impact of these policy solutions.
In addition to policy research, proactive research is needed to address the racial disparities related to drug use and addiction. From the opioid crisis, we have learned that large research initiatives can be mounted that engage multiple stakeholders—including the justice system (courts, prisons, jails) and the health care system—to cooperate toward the common purpose of reducing a devastating health problem. From the COVID-19 crisis, we have learned that the research enterprise can adapt and rapidly mobilize to address critical threats. These lessons can be applied to reduce systemic inequities in how addiction is addressed and to advance access to high-quality addiction care for all people who need it, whatever their race or background.
With this in mind, the National Institute on Drug Abuse is redoubling its focus on vulnerabilities and progression of substance use and addiction in minority populations [26]. We are exploring research partnerships with state and local agencies and private health systems to develop ways to eliminate systemic barriers to addiction care. We are also funding research on the effects of alternative models of regulating and decriminalizing drugs in parts of the world where such natural experiments are already occurring.
People with substance use disorders need treatment, not punishment, and drug use disorders should be approached with a demand for high-quality care and with compassion for those affected. With a will to achieve racial equity in delivering compassionate treatment and the ability to use science to guide us toward more equitable models of addressing addiction, I believe such a goal is achievable.