How can psychiatrists improve substance use treatment for Black and pediatric patients?
The highly publicized death of 54-year-old actor, Michael K. Williams, confirmed to be due to an overdose of heroin, cocaine, and fentanyl,1 was a sobering reminder that the opioid crisis is far from a problem limited to white Americans, although it has often been portrayed as such.2
Williams spoke openly about his own struggles with substance abuse, and celebrities disclosing mental illness can be a powerful method to increase help-seeking behaviors, especially for minoritized communities.3,4 In addition, he was quite invested in community work for children, founding Making Kids Win, a charitable organization that creates community centers to provide children with safe places to play and to learn. Williams himself experienced significant childhood trauma and admitted that he began to use substances as an adolescent to self-medicate.5 In fact, studies have shown that most adults who struggle with substance use disorders (SUDs) begin using substances before the age of 18.6 If psychiatrists want to combat the opioid epidemic, they must appreciate the needs of often-overlooked communities and start early—in childhood and adolescence.
Overlooked and At Risk
I recently attended a lecture about the effects of maternal opioid use on newborns. The presenter showed slides depicting mothers with opioid use disorders (OUDs) through a humanizing, rather than criminalizing, lens. All these mothers happened to be white. This was a particularly troubling coincidence, given the racialization of drug use and the racist pattern in the media—the favorable portrayal of rural and suburban white opioid users versus the unfavorable portrayal of black opioid users living in urban communities.7 Black Americans with OUDs are too often represented as poor, urban, criminals injecting opioids. This is a racially inaccurate depiction in and of itself, given that Black individuals with OUDs also live in the suburbs and in rural areas.
In 2017, the US Department of Health and Human Services declared the opioid epidemic a public health emergency after witnessing the monumental number of deaths due to opioid overdose.8 Since then and through 2019, although white deaths have been on the decline, opioid overdose deaths in Black Americans, and in particular in Black men, have been increasing.9 Synthetic opioids have hit Black communities disproportionately hard. From 2011 to 2016, Black Americans had the greatest increase in opioid-related death rates due to synthetic opioids, such as fentanyl,10 and from 2016 to 2017, Black Americans experienced a 61% increase in synthetic opioid fatal overdoses, compared to a 45% increase in white Americans.11
The current interventions used for OUDs, and arguably SUDs overall, are not working optimally for everyone. To be sure, white individuals have been harmed by the opioid crisis, and before the onset of fentanyl they had the highest rates and numbers of deaths due to opioid overdose.9 However, the opioid crisis is not only harming white people, and Black people are often left out when it comes to OUD interventions.
One Size Will Not Fit All
OUD treatment interventions should not be the same for all populations, because all populations are not treated equally when it comes to OUDs. The racist war on drugs, which disproportionately targeted Black populations,12 is only one example. Black individuals are disproportionately criminalized for SUDs, making it more difficult for them to trust and therefore access substance use treatment. Even though white individuals are more likely to sell drugs than Black individuals, Black individuals are more likely to be arrested for it.13 Black Americans are also more likely to be arrested for drug possession, even though white and Black individuals use substances at similar rates.
Racial disparities exist even in the distribution of psychopharmacological treatment for OUDs.9 There is differential access to buprenorphine and methadone, with the former less likely to be available in Black communities versus the latter. Methadone requires daily appointments, while buprenorphine is a take-home-pill. In essence, the more convenient treatment is less accessible for Black people. OUD interventions must do more to target Black communities specifically, and advertisements and slides for OUD interventions that feature white-only families misrepresent the true demographics of the epidemic. Black patients must be reassured that their SUDs will be humanized and treated as psychiatric disorders, not as punishable crimes.
Children in the Epidemic
During the opioid crisis, there has been less attention on the impact of OUD on children and adolescents. Although a myriad of research studies exist on OUDs’ impact on newborns, children 1 year or older get less attention when it comes to OUD research, with only 2% of federal funding for addiction research focusing on children or families.14 Beyond research, there is a need for clinical training on navigating OUDs in children and adolescents—and additionally, helping to prevent them. Children and adolescents of parents with OUDs should receive anticipatory guidance about opioid use, including support in understanding why they may be at greater risk for developing an OUD.
To be sure, child and adolescent psychiatrists have these sorts of conversations with their patients individually all the time, but having these conversations (or not) is often left up to the psychiatrist’s discretion, rather than having it be a standard of care. As an adult/child psychiatry resident, I have received the bulk of my training in SUDs from my time with adults, rather than with children.
While we are certainly trained to ask about SUDs in children and to monitor and treat them once they occur, what about preventing them? Perhaps newborns who suffer from neonatal abstinence syndrome should be flagged to receive preventative SUD care when they reach a certain age, although the long-term psychiatric outcomes of newborns exposed to opioids in utero is still a subject very much debated.15 Perhaps children who are exposed to trauma should be counseled about the risk of engaging in substance use, among risky behaviors, in an attempt to cope, especially if these children are already being seen by a child and adolescent psychiatrist for other reasons. One thing is for sure, the opioid crisis is far from a white people problem or an adult problem, for that matter. And, sadly, it is far from over.
Dr Calhoun is an adult/child psychiatry resident at Yale Child Study Center/Yale School of Medicine. She is also a Public Voices Fellow of the OpEd Project at Yale University.
1. Gold M, Bromwich JE. Michael K. Williams died of a drug overdose, authorities say. New York Times. September 27, 2021. Accessed September 26, 2021.
2. Shihipar A. The opioid crisis isn’t white. New York Times. February 26, 2019. Accessed September 26, 2021.
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4. Murray E. Michael K. Williams never hid his addiction struggles. Addiction Center. September 9, 2021. Accessed September 30, 2021.
5. Jackson D. Everything Michael K. Williams has said about addiction and his mental health struggles. People Magazine. September 24, 2021. Accessed September 26, 2021.
6. National Institute on Drug Abuse. Principles of adolescent substance use disorder treatment: a research-based guide. Revised January 2014. Accessed September 30, 2021.
7. Netherland J, Hansen HB. The war on drugs that wasn’t: wasted whiteness, “dirty doctors,” and race in media coverage of prescription opioid misuse. Cult Med Psychiatry. 2016;40(4):664-686.
8. US Department of Health and Human Services. HHS acting secretary declares public health emergency to address national opioid crisis. October 26, 2017. Accessed September 26, 2021.
9. White C. Progress against the opioid epidemic is not reaching Black Americans. Health City. February 8, 2021. Accessed September 26, 2021.
10. Agency for Healthcare Research and Quality. Blacks experiencing fast-rising rates of overdose deaths involving synthetic opioids other than methadone. February 2020. Accessed September 26, 2021.
11. Goodnough A. In cities where it once reigned, heroin is disappearing. New York Times. May 18, 2019. Accessed September 26, 2021.
12. United States Sentencing Commission. 2015 report to the Congress: impact of the fair sentencing act of 2010. 2015. Accessed September 26, 2021.
13. Ingraham C. White people are more likely to deal drugs, but black people are more likely to get arrested for it. The Washington Post. September 30, 2014. Accessed September 30, 2021.
14. Winstanley EL, Stover AN. The impact of the opioid epidemic on children and adolescents. Clin Ther. 2019;41(9):1655-1662.
15. Larson JJ, Graham DL, Singer LT, et al. Cognitive and behavioral impact on children exposed to opioids during pregnancy. Pediatrics. 2019;144(2):e20190514.