Overdose rates are higher in areas where people live in poverty and even higher among people of color living in poverty. In the last decade in Maryland, the proportion of opioid-overdose deaths involving Black people has continually risen, while the proportion involving white people has declined, mirroring nationwide trends. This past year, the disparity has worsened.
Drug-related deaths for Black Americans have persistently climbed. Within Maryland, Black people over 55 had more opioid-overdose deaths in 2020 than any other demographic, with 56.6% more deaths than white people over 55. It is perhaps no coincidence that nationally, Black people over 55 were 26% more likely than white people to lose their jobs between April and October of last year, as the pandemic swept the globe. COVID-19 has exacerbated existing societal conditions that make it next to impossible for people experiencing poverty to make a living. This means that for people with low incomes and a substance use disorder, they are more likely to continue to use, to use in unsafe circumstances and to die.
Why are poverty and marginalization related to worse substance use outcomes? In a nutshell, restricted access to basic needs puts tremendous stress on a person, and chronic and severe stress are major factors in developing substance use disorders. With financial hardship comes other stressors, like housing instability, environmental toxin exposure and less health care access. This is an even greater hardship for people of color, who endure systemic racism and may live in areas of concentrated disinvestment (high poverty, more policing, worse public services, less access to quality substance use treatment).
If we know that poverty increases overdose likelihood, isn’t it obvious that financial stability should be a treatment priority? This requires a paradigm shift in substance use treatment that would interrupt the structural problems feeding the poverty cycle. There is promising research around guaranteed income and cash transfer programs that demonstrate positive mental health and income outcomes. And while there is pushback that money given to people experiencing poverty would be spent on alcohol and drugs, there is data that show otherwise.
Recently, a guaranteed income program in Stockton, California, gave $500 a month to people at or below the median income and found that people spent less than 1% of their money on tobacco and alcohol. In Baltimore, Mayor Brandon Scott joined Mayors for a Guaranteed Income, committing to implementing a guaranteed income pilot. And Maryland’s nonprofit Job Opportunities Task Force is dedicated to creating meaningful employment for low-wage workers. While workforce programs developed by and for people with substance use disorders are lacking, let these initiatives inspire us as we imagine innovation in this area.
When exploring solutions for low-income populations and its relationship to opioid overdose we must also address racial inequity. Black people are more than twice as likely as whites to not have access to substance use or mental health treatment. Black people are also prescribed buprenorphine, an opioid medication with less stigma and more convenience than methadone, less than whites. At the same time, Black people are criminalized and dehumanized for drug use at greater rates than whites. By continuing to apply race-neutral programs via race-neutral policies we uphold systems of white supremacy in substance use treatment. We need culturally sensitive programs that purposely honor the humanity of Black people, and we should direct resources to Black-led service organizations that have a track-record of success. There are promising examples of faith-based treatments specifically for Black people with substance use disorders. Policy changes that target the decriminalization of drug use would interrupt harm that Black people face and benefit all society by removing the burden of a criminal justice stamp.
Substance use disorder affects us all, no matter your race, income or education level. As a society, we must now ensure that the recovery process is also “equal opportunity” so that each person with a substance use disorder has an equal chance for continued life.
People with substance use disorders are human beings who are innately deserving of food and shelter. Once we honor the humanity of this population in our community by addressing basic needs, we diminish stressors that may lead to drug use in the first place.