What’s behind the increase in overdose deaths for Black Americans?

Sign up for the On Point newsletter here. 

Opioid overdose deaths for Black people in America have skyrocketed. For younger Black Americans, they’ve almost doubled.

Some say race also affects who gets medication and addiction treatment.

"That has been really concentrated among Black and brown people because they do not have the same access to the lifesaving interventions involving treatments, harm reductions, the white communities have now taken advantage of," Helena Hansen says.

Today, On Point: The rise in opioid overdose among Black Americans and how race affects drug use and our response to it.

Helena Hansen, professor of psychiatry and anthropology at UCLA. Co-author with Jules Netherland and David Herzberg of "Whiteout: How Racial Capitalism Changed the Color of Opioids in America."

Robert Suarez, an opioid user and advocate from NYC.

Caty Simon, an opioid user and advocate from Holyoke, Mass.

Excerpt from "Whiteout." Reprinted with permission. Not to be reprinted without permission of the publisher. All rights reserved.

Part I

DEBORAH BECKER: I’m Deborah Becker. In for Meghna Chakrabarti. And this is On Point. Black Americans are dying from opioid overdoses at increasingly alarming rates. So much so that the death toll has exceeded White Americans for the first time in more than two decades.

In 2020, overdose rates increased by 44% for all Black Americans, and those rates are only going up — according to the CDC. Mostly, driven by the powerful synthetic opioid Fentanyl.

Many people say they’re not surprised by these numbers – white people addicted to opioids are more likely to get treatment, while people of color are more likely to face criminal charges.

Robert Suarez knows this all to well. He’s a 62-year-old Black man from New York City.

He started using street heroin in his fifties – for back and hip pain after his doctors wouldn’t prescribe opioids.

ROBERT SUAREZ: I continued to use after that basically for pain management. But I started using more and more basically. Unfortunately, I started using more and more to control the pain.

BECKER: Robert soon lost control and found himself buying drugs two to four times a day. Sometimes he'd be stopped by police.

SUAREZ: There was a distinct difference, as far as, like with the court system. The prosecutor was quick to want to give me jail time. And when it came to my white brothers and sisters, they got more leniency or even a pass. And they would walk out of the courtroom where I was on my way to Riker’s Island or something like that.

BECKER: Robert says he was probably arrested on drug charges at least eight- or nine-times - serving sentences from 30-days to as long as 6 months.

He knew street heroin was dangerous because most of it was either laced with fentanyl or was just fentanyl. He says he wanted to stop using, but his body relied on the opioids and without them he would get really sick. So, he decided to try methadone, a medication used to treat addiction by providing enough opioid so the body doesn’t get sick, and the brain doesn’t get high. But to get methadone – Robert had to go to a clinic every day for each dose.

SUAREZ: So, it was morning, and it was a crazy time in the morning. You had to be there like, um, geez, I think it was like 5:30, 5:30 or 6 in the morning. And if I was late, that was it. Couldn't be dosed. If I didn't have, it was some kind of fee that you had to pay, if your insurance didn't cover the whole thing. If I didn't have that, I wouldn't be dosed.

BECKER: If Robert did miss a dose, he would get really sick from withdrawal. So sometimes he would resort to street drugs. He knew that if the clinic checked his urine, which it did daily, and he tested positive, he’d be punished again. And then he’d miss more doses.

SUAREZ: And, and I just, I could not take anymore. I just, you know, I'm better off buying drugs off the street. So, it was almost like it was designed for you to fail.

BECKER: Eventually Robert found a doctor who would prescribe Buprenorphine, often known under the brand name Suboxone. Unlike methadone - he could take the drug at home on his schedule, it prevented him from being dopesick and it helped with his pain.

SUAREZ: Oh, you have no idea how good I feel. I do not want to see another bag of heroin or fentanyl. If I never see bag of dope for the rest of my life, I'm good.

BECKER: But Buprenorphine is harder to find if you are Black in America. According to a 2019 study, white Americans were three to four times as likely as Blacks to receive Buprenorphine. Some of the reasons for that are that it’s only available by prescription and typically requires insurance — or in some cases cash.

SUAREZ: Every doctor should be able to turn to their patient, if the patient is a heroin user and say, do you want me to prescribe you Suboxone? Every individual, whether they are Black or white should be able to receive that. It's such a, in my mind, it's such a game changer.

BECKER: That was Robert Suarez of New York City. He’s been Suboxone, or Buprenorphine for about a month and says he plans to stay on it.

We want to spend the rest of this hour diving into a shift in the opioid epidemic and how it appears to have gone from a largely white problem to now a Black one. We're going to look at some of the racial factors that helped create the U.S. opioid epidemic as we know it, and we're going to talk about possible solutions.

Joining me now is Helena Hansen. She’s the co-author of Whiteout: How Racial Capitalism Changed the Color of Opioids in America. The book came out earlier this year, and you can find an excerpt of it on our website.

She’s a Professor of Psychiatry and Anthropology at the University of California, Los Angeles. Previously she practiced addiction psychiatry at Bellevue Hospital in New York, while serving as a professor of psychiatry and anthropology at New York University.

Welcome Helena, to On Point.

HELENA HANSEN: Thank you. Thanks for having me.

BECKER: Thanks for being with us. And this is a complicated story with a lot of tentacles, and we just heard from Robert. But I want to start out latest overdose death data, some disturbing statistics from the Centers for Disease Control showing 44%, 44% increase for Black people in terms of opioid overdose deaths.

I wonder what you make of those numbers? What's the message in them?

HANSEN: It is indeed a complicated story, but the bottom line is probably not too complicated. Robert's story is in many ways, not surprising to anyone who's grown up in the United States over the past few decades. The story of a Black man addicted to heroin who gets repeated punishment for his heroin habit.

The, I guess, the surprising thing at the end is that he finally accessed Buprenorphine treatment, maintenance treatment, which is a brand-new development in the United States, on the heels of 80 years of prohibition of doctors being able to maintain someone who's opiate addicted on opioids as a treatment.

So the medicine, he talked about Buprenorphine, is an opioid. It's one that's much safer certainly than what's on the street and possibly even safer than methadone. But is largely inaccessible to Black and brown Americans. And the story of how Robert got into this position is really the story that I and my co-authors, Jules Netherland and David Herzberg tell in our book.

But to make a long story short, the surprising thing of the late nineties to early 2000's was the quote0unquote white face of opioid addiction. If you were to read news stories from that period of time, you would see headline after headline about the surprising quote-unquote white face of addiction.

First, it was prescription opioids, and then it transformed to heroin. And so you've gotta, I think the really interesting thing here is the story of white Americans and the surprise of white addiction that was covered in the news media since the image of who is an opioid or heroin addict has for so many decades been a Black or brown face.

And it's driven the kind of punishing drug policies that we see Robert experienced whenever he came to the attention of authorities. So with this new white face of addiction that was really created based on stereotypes of white people being less susceptible to addiction. Pharmaceutical manufacturers in the mid 1990s, starting with Purdue Pharmaceuticals and Baer Oxycontin, that was FDA approved as, quote-unquote, a minimally addictive opioid pain reliever.

The manufacturers of that generation of sustained release opioids that were really sold to regulators as less addictive than other opioids. The manufacturers were able to do very aggressive marketing and get around regulators and get FDA approval on the basis of the white image of the clientele that they knew that they'd be marketing to.

In the United States, white Americans are the ones that pharmaceutical companies, white Americans with good insurance, better off white Americans who can buy expensive, newly patented pharmaceuticals, meaning the manufacturer has exclusive rights in a certain period of time to market that opioid or that pharmaceutical. White Americans are the first clientele normally for a new drug that is sold as having advantages over older versions.

And they were able to use that image to create a whole other track of opioid, legal opioid prescribing and to very aggressively market. So that is the story of white opioids. That is the surprise in the story. And it ends with a whole other tier of treatment.

BECKER: Let's unpack a little bit first. So what I'd like to do is, let's start from the beginning so folks know what we're talking about, so if we step back and try to look at the big picture, let's talk about how we got here. Let's create a timeline for folks so they understand what we're talking about, how this went from a problem in communities of color.

To the white community and now back apparently to communities of color. So 50, 60 years ago when we were dealing with a heroin epidemic, what did it look like then, and what was addiction treatment then? If you were just to describe it briefly to folks who may not know.

HANSEN: Yeah. So I think if we're going 50, 60 years back we're looking at the 1960s to '70s.

A period of time in the United States when there were race riots, the cities in the United States were burning to the ground. The unemployment rate for Black Americans was twice that of white Americans. Lots of racial violence. And in the media, actually, heroin was one of the things to which these riots were attributed.

President Nixon in launching the War on Drugs in 1971 was really pointing not only to returning Vietnam veterans who had been exposed to heroin in Southeast Asia, but also to inner city, Black and brown people who were said to be violent, were said to be heroin addicted, and that was what, heroin was the underlying problem.

This led to white flight from the cities. This led to again, the launch of the War on Drugs and alongside very punitive drug policies that led to incarceration and a framing of the heroin problem that actually had developed there as the heroin cartels run by organized crime.

Part II

BECKER: This is On Point. I'm Deborah Becker. Today we're talking about the skyrocketing opioid overdose death rate for Black Americans and the role of race in the nation's opioid epidemic. I'm speaking with Helena Hansen. She's co-author of the book "Whiteout: How Racial Capitalism Changed the Color of Opioids in America."

She's also a professor of psychiatry and anthropology at UCLA. And Helena we were talking before the break about a timeline of where we were when it was primarily heroin addiction in the U.S. affecting communities of color and the real criminalization of drug use then. Let's jump ahead 20 years to opioid painkillers, which you briefly mentioned before, and you said were then marketed to white folks, and this is really the start of the opioid epidemic becoming a white problem.

Can you explain?

HANSEN: Yes. Thank you. So if we fast forward from the first war on drugs in the '60s to '70s to the 1990s when a new a new generation of opioids were approved by the FDA as minimally addictive. The irony there is that since those opioids were marketed to white Americans, that was really the clientele that, No. 1, had the resources to buy this expensive new opioid.

No. 2, were seen by regulators as at less risk of addiction. Not a group that needed to be monitored in the same way. So these opioids were legalized. They were very aggressively marketed, led to a tenfold increase in opioid prescribing across the country with the fastest uptick in predominantly white, rural, and suburban areas.

And that was then seen as a white crisis when the opioid overdose death rates started to rise in those neighborhoods. It was seen as a crisis of quote-unquote "suburban youth." And Congress essentially created a whole other tier of drug policy in response to this group. It was not a group that lent itself to very punitive policies.

Didn't lent itself to punishing the user, so to speak, as it had in the '60s to '70s heroin crisis. Really it was labeled a health crisis as opposed to a crisis of crime, as it had been in the '60s to '70s. This was a health crisis, and it required a medical tier of drug policy.

So that is where Buprenorphine, otherwise known as Suboxone, came into play. It was legalized for private office prescription. And people who had access to this treatment, because they had access to these private doctors who are certified to prescribe it, were not subject to the kind of punishment that Robert's story illustrates, they were subject to medical treatment and this was seen, the New York Times reported on it as a quote-unquote "kinder, gentler response to drugs" than the U.S. had engaged in before.

So essentially this was a white tier of treatment, as opposed to punishment that was created and that was on the heels of opioids that were specifically marketed to white Americans with all the harms that came after that to white Americans.

BECKER: And now we're back to the opioid crisis, really hitting the Black community hard, especially young Black Americans. An 86% jump in the overdose death rate for young Black Americans in 2020.

Is the racism in this country an increasingly dangerous drug supply? Are we seeing the collision of these two things or what's happening?

HANSEN: I think that's a really apt way to put it. So we're seeing the convergence of two things. One is that the cartels that handle opioids and heroin got an enormous boost from the aggressive, but legal marketing that opioid manufacturers engaged in from the late '90s to the 2000's.

So what happened was that, as I mentioned, the opioid prescribing rate went up very high, in predominantly white communities and areas that hadn't had the big volume of, for example, heroin traffic that had in past been constrained to large port cities. Heron's bulky, it's hard to smuggle.

And so it really was large port cities that had been the centers for heroin trade, up until the opioid manufacturers like Purdue Pharma of the 1990s got around regulators. Now, what you had was a whole generation of predominantly white Americans in small town, rural and suburban America, physically dependent on opioids, because of this aggressive marketing and just saturation of these communities with prescription opioids. Congress, rather than punishing these white and often middle-class to affluent users instead really focused on the manufacturers and on the prescribers.

So for the first time, they created this prescription drug monitoring program that really punished with criminal sanctions physician prescribers and pharmacists who didn't follow protocol around a prescription drug monitoring database. And they also, the manufacturers of the opioids came up with tamper-resistant formulations of opioids that were much harder to inject or snort.

What that did was it left a whole generation of white, predominantly white suburban, small town and rural Americans physically dependent on opioids without the supply of prescription opioids that they once had. They turned to heroin, they turned to the same cartels that in the past had been supplying large port cities.

This led to a huge boom in heroin trade. But then as that trade really grew and there was some crackdown on the heroin cartels, they switched to fentanyl and other synthetic opioids that are much, much lighter, much more potent. It takes about a hundredth the weight of fentanyl to have the same physical effect as heroin.

100 times the amount of heroin, so much easier to smuggle.

BECKER: Cheaper. Cheaper, right?

HANSEN: So the nation's whole drug supply got much — Yeah, and much cheaper as well. The nation's drug supply got much more toxic, and everyone has been affected by this. Now what we see is that Black Americans, because they have less access to treatment, the treatment tier that I just described, private office treatment with Buprenorphine or Suboxone, was really designed with insured Americans with access to private doctors in mind, and that's not Black Americans.

Black Americans are much less likely to be insured. They're much less likely to have commercial or private insurance and access to the doctors who were certified to prescribe Buprenorphine, which was a small subset of American physicians.

So this was not a drug policy that was designed with Black Americans in mind. It was designed with predominantly white Americans with access to private insurance and private doctors in mind. So they have not had access to the same treatment. They haven't had access to the same amount of harm reduction, meaning measures to enable people to get safe supplies, test their supplies.

And what we're seeing is the effects now of very toxic street supplies of opioids of any kind with Black Americans disproportionately exposed to those markets, they're not likely to have the resources or the power to get access to safer supplies of drugs. They're also not likely to get access to treatment or services that would protect them from overdose.

So all Americans were then exposed to this much more toxic street supply, following what we call the iron law of prohibition. Meaning the more crackdown on a drug as illegal there is, the more toxic the street supply gets. That has applied across the board, starting with alcohol prohibition in the 1920s.

Up to now, we're seeing fentanyl's the outcome of that. And we're seeing Black Americans really paying the heaviest price of that, as white Americans have been able to take advantage of this medical tier of drug policy that was created for them, starting in the late '90s to 2000's.

BECKER: I want to hear from someone else who can help bring your point home with a personal story here.

Earlier in the show, we heard from Robert Suarez in New York. He told us about his experience with addiction and treatment as a Black man in America. And we want to contrast Robert's story with the story of Caty Simon, who's from Holyoke, Massachusetts, she's 42. She's been an opioid user for decades. And let's listen to a bit of her story.

She says she started when she was very young.

CATY SIMON: The very first time as a little girl that I had read about opioids, I thought, this is for me. I want to be able to feel like this, whatever these people are describing.

BECKER: And in college she started using street drugs. She quickly became hooked. She continued to use for 20 years.

Yes, at times, she did face criminal charges, but she says most of them were dismissed. And she says that's because she's white.

SIMON: There were so many situations that I could navigate through having my white skin, my social capital, my educational capital. That I was described as articulate, as a white person, happened to be able to save me from a lot of things, and I didn't have that many street smarts, and I was smart enough to know whom to hang out with and whom to develop reciprocal relationships with, in order to stay safe.

But not so smart that if I was a person of color, I would have gotten criminalized way more often than I did. So I managed to avoid criminalization basically by virtue of my whiteness.

BECKER: And that privilege, Simon says, carried over to treatment. She is now on methadone, and she says at the clinic sometimes she has gotten advantages not offered to other patients.

SIMON: Like they have even given me some exceptions in terms of my business travel, which I am sure that they would not give a person of color. They see me as, "Oh good, local girl. Done good."

BECKER: That's Caty Simon of Holyoke, Massachusetts, talking about addiction and addiction treatment and how her race affects both of those things.

We're joined by Helena Hansen, who is a professor of psychiatry and anthropology at the University of California at Los Angeles. And I'm wondering, professor, when you hear Caty Simon's story especially contrasted with Robert's story that we heard earlier in the show. Do you think that is really, to your point, of how race is really a factor in the opioid epidemic that we know in the U.S.?

HANSEN: I do. Caty describes on the ground her experience of a very systemic way that racism is now operating through our drug policy. She's describing her experience as a white person struggling with opioid addiction as much less punitive, much less criminalized. And one could say, "Oh, it's just the bias of the people who are treating her in the methadone clinic, or it's the bias of the judges that were seeing her when she was charged."

But really what we argue in our book Whiteout is that it isn't actually the sum total of individual attitudes of people, it's actually baked into the system. So, if you, as I mentioned, if you study the congressional record in the late 1990s, when they're trying to figure out what to do about this unexpected epidemic of white opioid overdose in small town and suburban America, it's very clear that they're struggling to come up with a tailored set of responses for white and often more affluent or middle-class Americans.

In the Congressional record, they talk about people who quote-unquote wouldn't otherwise be associated with the term addiction. And really talk in much more humanizing and valuing terms about this generation of suburban youth who would not be, quote-unquote, "A good fit for methadone treatment because they're not hardcore users."

And so that's the kind of imagery, the racial imagery that's baked into the policies themselves. So regardless of what the attitudes are of the treaters or of the judges, we now have a two-tiered system of drug policy with this medicalized tier of Buprenorphine or Suboxone treatment.

The odd thing here is that Caty is describing methadone treatment, but she's describing even within a methadone treatment system that was initially designed with Black and brown Americans in mind, in the late '60s, early '70s, which is why it's itself a much more punitive system.

Not really part of clinical care, otherwise segregated off in parts of town, low-income parts of town, far away from the parent hospitals and clinics with directly observed dosing. Every day, lots of security guards, people, security guards, observing people, giving urine samples for drug testing. It's a very different setting than private office treatment with Buprenorphine, where you get a prescription for 30 days and you take it at home. So it's a much different system and what Caty is describing is what it feels like to be within one system as opposed to another.

So if we had spoken, as I did, with white Americans on Buprenorphine treatment, we would get a picture of, very often, being treated as though one had any other chronic condition, and that's exactly what the policy was designed to do, to create an experience for someone with opioid addiction, of being treated for opioid addiction as though it was diabetes, hypertension, asthma, the policymakers and the drug treatment advocates who created the Buprenorphine private office treatment track, or tier of a drug policy specifically said that's what they wanted.

They wanted people to be treated as though they had any other chronic condition that would be treated in the same way by private doctor and private office. And with the same methods, using a long-term maintenance medication. And so that's what we're seeing on the ground. These were specifically created systems, as opposed to the very punitive and criminalizing system that Robert describes being put through.

BECKER: And we should point out that some of the rules for methadone changed, right, during the pandemic to allow some patients to take doses at home to prevent people from gathering at a clinic every day. And there is some flexibility now, although different clinics and states can interpret that as they want. So is that, we should say, that there is a little bit of flexibility in methadone. It isn't always, everyone has to show up at the clinic every day at the same time to get their dose.

The pandemic changed that a bit.

HANSEN: It did change temporarily and there's really a struggle right now to try to maintain the gains in the methadone treatment system that were made under COVID. Because what happened was the drug policy advocates who really were pushing for methadone treatment, which is much more common among Black and brown Americans, if they do get treatment at all, which they often don't, they're much more likely to be channeled to methadone as opposed to Buprenorphine, otherwise known as Suboxone, as you mentioned in the beginning of the show.

So white Americans are three to four times as likely as Black Americans when they're presenting to a doctor with opioid addiction to get Buprenorphine, otherwise known as Suboxone, which is really a state-of-the-art treatment. So Black and brown Americans, when they do get treatment, are much more likely to be channeled to methadone because it's a treatment system that was created for them under the War on Drugs.

If we look at that, what's happening now is on a state-by-state basis, methadone policies are being reexamined. A lot of states are choosing to go back to the old ways, of requiring people to come in every day for observed treatment. This is something that makes it very hard for people who are trying to keep a job.

For example, they have to show up to the clinic every day at a time dictated by the clinic itself to be observed, taking their methadone with the idea that this is going to prevent them from cheeking the methadone, putting, hiding it in their cheek and then going out, spinning into a cup and selling it on the street markets.

This is the kind of criminalizing approach that methadone clinics really are based on. Under COVID, people were able to take many more take home doses. And so it began, methadone began to look a little bit more like Buprenorphine treatment, that you were able to take your medicine at home.

And this was a big advantage under COVID, as you can imagine. You weren't exposed to the virus. But a lot of states are going back to the old ways. And that again, is an example of systemic or structural racism.

Part III

BECKER: We've been talking about how difficult it is for Black Americans to get treatment and how it's very different for a Black American to get treatment as opposed to a White American.

And I'm wondering, Helena, if you could tell us what about the populations, the part of the white population, that also appears to be struggling to get treatment. And also, can't always get the preferred treatment Buprenorphine and would have to get methadone if they became addicted. Are there parts of the white population that have been left out in this as well?

HANSEN: Thank you for that question because it's on point, apropos. As I mentioned, the whole tier of Buprenorphine or Suboxone treatment that was created as of the late '90s, early 2000's to respond to the quote-unquote suburban opioid problem that Congress was debating was really designed for people with private insurance.

Types of insurance that would enable them to get a very expensive new medication at market rates through a private doctor. And there was an elaborate system developed for certifying physicians who voluntarily would undergo eight hours of additional training to prescribe Buprenorphine.

This was quite a deliberate way of making buprenorphine available to a very specific and slender segment of the U.S. population, because the doctors who are incentivized to prescribe Buprenorphine were those that could charge market rates, in New York City it was of $2,000 for first half hour visit to get started on Buprenorphine. Very lucrative for doctors in private practice, not something that doctors in the publicly insured Medicaid, Medicare insured system were going to get involved in. They had no incentive to do that kind of eight-hour certification training.

They already were overloaded with too many patients. And they were not looking to make extra time in their schedule for patients that were seen as complicated, when they barely could keep up with the huge patient loads that they had. This was feedback that I got doing interviews with doctors on the ground in the early 2000's.

So this was a treatment track created for people with the kind of insurance, and kind of access to private doctors that would get them these especially certified Buprenorphine doctors. And it's not a surprise that poor, white Americans were left out of that picture, as well as poor Black and brown Americans.

So we do see large segments of the U.S. population, I'm thinking about places like the Appalachian Mountains where prescription opioids were heavily marketed in the '90s, to people who had work-related injuries. They were working in mining industries, heavy machinery-oriented industries, were getting injured and had Workers' Comp that would cover these new prescription opioids.

And then these communities were just awash with opioids and then heroin, then fentanyl, but they did not have the kind of insurance and access to doctors that would get them Buprenorphine. And we see in those communities that poor white Americans are, first of all, being arrested and imprisoned at rates comparable to Black Americans, and they are not getting access to this new private office treatment of Buprenorphine.

BECKER: So let's talk about what needs to change to try to help. Is it treatment? I read certainly that because there's a great deal of mistrust of the health care system, particularly in the Black community, perhaps putting peer groups in churches to try to help people. Because certainly the peer group model has been shown to help certain people get into recovery from addiction. What are some of the things that you think are key to try to get out of this?

HANSEN: I am so glad that you asked, because this is what we should be asking ourselves as a country. We are seeing really one of the very negative outcomes of the fact that we don't have a national health plan.

We don't have universal access to doctors and prescribers, so for any kind of medical intervention, already we're limiting who can take advantage of that. At the same time that our very for-profit healthcare system is enabling the kind of aggressive, very aggressive marketing of new opioids that happened in the late '90s to 2000's. And really, everyone is harmed by it.

You and I have been discussing all of the various ways the systemic or structural racism in drug policy and drug treatment have played out with the opioid crisis. But it's not limited to opioids. There's so many other ways that the Americans across the board are really paying the price, including white Americans. And in many cases, even affluent white Americans who were dying off at high rates from opioid overdose, as recently as the early 2000's, before they really got a handle on this new medical tier of Buprenorphine treatment.

So we are in a profit-oriented, highly unequal health care system. We have to address that, as just a fundamental principle. We also have to pay so much more attention to social inequalities and poverty as driving root causes of the problems that we're seeing. We're, as you mentioned, in the throes of the highest overdose death rates that we've seen in history, and certainly by far the highest in the entire world.

One thing that distinguishes the United States from other industrialized countries in Western Europe, east Asia, and Canada, for example, we pay the most for health care of any country in the entire world per capita, about almost 20% of our GDP, and we get the worst health outcomes of any industrialized country in the world, any of our peer countries by far.

BECKER: And of course, when we're talking about drug policy, and that can also result in criminalization, and you talked about folks now saying we can't arrest our way out of this. We hear this frequently now from law enforcement. And yet what seems to be most current is that there's this push for increased penalties, especially for even street level, low-level drug dealers.

Charging people who sell drugs if there is a fatal overdose, charging them with manslaughter. Doing more to go after anybody who's involved in this, because fentanyl is so deadly. Why are we going back to these tough penalties when they clearly didn't work?

HANSEN: Yeah, what a great question. So back to the iron law of prohibition that I was describing before. That what we're seeing in the face of Fentanyl, an incredibly toxic substance permeating our street supplies, is a call for the same old supply side, interjection, harsh punishment for quote-unquote dealers. That has been our mantra as a country for the past 100 years, and it's what's driven our horrible outcomes.

So if, again, international comparison, if we look, if we compare ourselves to just about any Western European or Country or Canada where they have tried a demand side strategy, meaning address the social problems that are driving people to use drugs, particularly on the illegal markets to begin with.

Regulate, rather than heavily criminalized drugs. Provide not only medical treatment, but social safety nets, assistance with employment, housing, health care in general, access to health. So there's just so many things we haven't tried that other Western European countries and Canada with much, much better outcomes when it comes to their drug policies, they have put into place.

So we're violating the iron law of Prohibition yet again. A lot of it is the racial imagery, because there's still such a negative Black and brown kind of face attached to who's a dealer, as opposed to a user of opioids. That's also true. We did a media content analysis about this and when dealers, quote-unquote opioid dealers were represented, they were Black and brown faces.

Now we're hearing that it's Mexicans crossing the border who are responsible for our fentanyl crisis. So we're back into the same track of the trap of the racial imagery that has driven prohibitionist policies for a century in this country and gotten us the really horrible outcomes that we see.

BECKER: And of course, we also know from all of this, especially when talking about opioids in particular, that incarceration just increases the overdose death rate.

HANSEN: Absolutely.

BECKER: Because someone who's incarcerated and then gets out has a much higher risk of then dying of an opioid overdose.

We've got that problem.

HANSEN: Absolutely. Absolutely. When people are in prison or jail, and they're opioid dependent, they generally don't have access to those opioids. Their bodies become less tolerant to opioids. When they're released into an environment where their bodies are much more sensitive to opioids, they're much physiologically more vulnerable to overdose, but they're also released into a setting where they have even less access to housing, to health care, to employment, because of their criminal record, and they're released into a very toxic and dangerous drug market. So all of those things together greatly enhance the risk of overdose.

So the incarceration we're practicing actually is in itself a big risk factor for overdose, as you said.

BECKER: And what about safe consumption sites, where someone could use drugs under medical supervision to try to prevent death? Would that be, you mentioned some possible solutions, but I didn't hear you specify safe consumption sites.

Would that be an option, do you think?

HANSEN: Absolutely. So again, if we look to countries that have had much better outcomes than we have in terms of reducing overdose deaths, they have had very positive results from what we now call medically supervised overdose prevention sites. That's sites where people can use drugs without fear of arrest on site, and they have medical personnel nearby who can intervene if they overdose.

This is something that's counterintuitive to a lot of Americans who've been raised on this idea that the best response to illegal drug use or problematic drug use, whether it's legal or not, is to crack down, to arrest one's way out of it. It's actually been shown to dramatically reduce overdose death rates in those western European countries and Canada where it's been tried.

And so that's a very evidence-based approach that we should use. It shouldn't be the only thing. There's so many other things we haven't done, and I began to talk about the social inequalities. And the fact that we now talk about deaths of despair, often, to describe the very high rate of overdose in small town and rural and suburban.

Well, mostly rural and small-town America. Places that were abandoned by manufacturing and mining companies. Starting in the '70s to '80s, where overdose death rates were really high after the prescription opioid manufacturers got through saturating those places with opioids, and then heroin cartels came, and fentanyl cartels followed.

We're talking about deaths of despair. And in fact, there's a lot of power to that phrase. We have to look at why people are so desperate. That they have the kind of problematic substance use that they have. Sociologists who've studied it showed that there's a very direct relationship to the thin social networks in these communities that are totally upended by high rates of unemployment and displacement.

And homelessness, so overdose rate, death rates correlate to social inequalities and social displacement. Until we address that, and we start really investing in communities, but with a real eye to racial equity. If we don't look at racial equity, we're going to end up recreating the same racial dynamics and investing disproportionately in economic development in white communities, and social support networks in white communities.

So we have to look at those communities that have been most harmed over the past many decades by drug policies, American drug policies, often Black and brown ones. Also, poor white communities have been harmed by these drug policies and really focus our investments there.

We really need to make sure that people are employed, they're socially connected, they have the relationships that sustain them as human beings, and thereby reduce the demand for the drugs.

That is the payoff. That's what other countries, our peer countries have shown over and over again.

BECKER: Our current treatment system, that's not the focus at all. So isn't that, so it makes it really difficult when your treatment system doesn't have all of those components to help people get into recovery and change this.

HANSEN: Absolutely. So I'll give you one quick example. My colleagues in the U.S. who are big advocates of Buprenorphine treatment expansion, they often point to France. Because in France they legalized Buprenorphine earlier than we did on the heels of an HIV and overdose epidemic in France. So it was legalized in the '90s for private office.

I would say general doctor use, I don't say private doctor use because in France they have a universal health care system. That's a very important distinction, between France and the U.S. So in France, they were able to reduce the overdose death rate by 80% in the first five years after Buprenorphine was introduced.

Now my colleagues in the U.S., they'll tell this story, but they'll leave out some key details. No. 1, the fact that France has universal health care. If you have an intervention that requires a doctor to prescribe and maintain you on a medication, you have to give access to health care. That's fundamental.

So we have to address that in this country. But they also leave out the fact that in France, Buprenorphine is largely distributed in community addiction centers that are very holistic, that provide not only the medical treatment, but they provide assistance with housing, with employment.

They have peer navigators, people of problem drug use who are there to guide people through the process and support their recovery. They also provide comprehensive health care alongside the Buprenorphine treatment. There are just so many things baked into their approach, and they did not launch Buprenorphine as a private market for white, affluent people, kind of an intervention.

They launched it as an intervention directed to poor, largely immigrant communities at the outskirts of French cities, which is the way that France is put together. So it was deliberately a public health intervention, directed to people who had the least access and who are at the most risk of death. And that is what we have not tried here, either.

We haven't tried a holistic approach with social services baked in, and we haven't tried launching all these initiatives as a public health intervention that specifically takes into account inequalities.

BECKER: Last couple seconds that we have left here. What about legalizing drugs as some countries have done?

Is that, would that help?

HANSEN: Absolutely. So I mentioned earlier regulating drugs. Because what we are seeing now, that's where the iron law of prohibition comes in. Again, what we did in the '20s and ended in the early '30s, was this experiment with --

BECKER: Couple seconds.

HANSEN: Illegalizing drugs and making them much more, so alcohol got so much more toxic, as a result. And that's what we're seeing with Fentanyl. So if we regulate rather than illegalize, we reduce the influence of criminal justice system, we increase the influence of the medical system.