Donna Murch’s masterful description of the roots of the opioid crisis coheres with our study of corporate pharmaceutical executives, addiction researchers, and medical practitioners. We too find that racial capital has played a central role in creating the “white” overdose epidemic through drug regulation, drug marketing, and law enforcement. Racial parsing has meant that even while pharmaceutical opioid markets grew out of control, drug-war style law enforcement continued to inflict its devastating harms, especially in black and brown communities.

Many of the same players now reap profits from treatments for the opioid dependence they helped to create.

But Big Pharma’s carefully constructed racial capital did not end with the creation of the opioid crisis; it endures in the U.S. national response. Many of the same players now reap profits from treatments for the opioid dependence they helped to create. And the structures of access are marked by many of the same racial privileges.

Our current research, as documented in our forthcoming book, exposes and pushes back against this newest incarnation of the racial capital encoded into pharmaceutical markets. We focus on the central difference between U.S. drug policy before and after the “white” opioid crisis: a new emphasis on clinical treatment as opposed to punishment, and, especially, on pharmaceutical maintenance with medication-assisted treatment (MAT). The expansion of MAT is laudable in many ways, but it poses new problems of its own.

Buprenorphine, itself an opioid and the primary medication being promoted for MAT, was developed in the 1990s as a treatment for opioid dependence and was federally deregulated so that it could be prescribed in doctors’ offices for use at home. This marked a radical departure from the stigmatized and tightly policed MAT traditionally provided in methadone clinics. Rather than being narrated as standard medical progress, however, this shift was narrated as the development of a treatment style appropriate for white people. As one official told Congress, methadone clinics “[tend] to be concentrated in urban areas” and “[are] a poor fit for the suburban spread of narcotic addiction” among “citizens who would not ordinarily be associated with the term addiction.” Deregulating buprenorphine was necessary, in other words, because methadone was seen as inappropriate for white clients. Unsurprisingly, access to buprenorphine through private-practice physicians has been profoundly disparate along racial, economic, and geographic lines.

Unequal access is not the only way racial capital functions in the buprenorphine-centric response to the opioid crisis. The U.S. federal opioid plan—as articulated in Trump’s opioid commission report, the 21st Century CURES Act of Congress, and the National Institutes of Health (NIH) HEAL initiative that it funds—emphasizes primary care–based expansion of MAT, largely buprenorphine maintenance. Related legislation has streamlined new drug approvals, reduced the FDA’s review process for new drugs, and provided major NIH funding for public-private drug development partnerships and clinical trials. Prioritizing individual-level treatment, these policies give short shrift to health infrastructure development or social intervention while offering a bonanza to pharmaceutical companies. There is little to no funding specifically focused on marginalized groups (as defined by race, class, gender, LGTBQ status). There is equally little for the health care access, social services, and economic supports (such as housing) that have been shown in prior studies of opioid dependence and of analogous epidemics (such as HIV) to be critical to the success of pharmaceutical treatments.

Racial capital has so greatly warped our engagement with the opioid crisis that we are at grave risk of missing a new phase of the crisis even as its harms grow. For example, while attention has been focused on deaths among whites, deaths among blacks have been rising steadily. In 2012 blacks made up 7 percent of opioid overdose deaths; in 2017 that number rose to 12 percent. An analysis of 2017 overdose death data in New York City revealed that, for the first time in eleven years, compared with whites and Latinos, black New Yorkers had the highest rate of drug overdose deaths.

In this New York is not alone: according to data from the Centers for Disease Control, blacks in urban areas across the country have seen the sharpest increase in overdose deaths in recent years, driven largely by fentanyl in the drug supply. Yet we have not seen the same kind of media attention we saw for increases in overdose deaths among whites. Nor have we seen the humanizing depictions of black opioid users that now frame whites struggling with opioids as blameless, with tragically wasted talents and with loving families. Thus, even as white racial capital helped produce the opioid crisis, it also threatens to limit any hard-won progress—including low-barrier access to buprenorphine—along lines of race and class.

In fact, quite the opposite: despite the well-funded emphasis on MAT, we have seen no corresponding effort to dismantle the punitive drug war apparatus that has historically been responsible for caging millions of black and brown people. In the past decade, arrests for drug violations have actually increased by 3.2 percent. Prosecutors, politicians, and the public have called for an increase in so-called drug-induced homicide prosecutions. A Drug Policy Alliance report on overdosing reported that “in 2017 alone, elected officials in at least thirteen states introduced bills to create new drug-induced homicide offenses or strengthen existing drug-induced homicide laws.” Although purportedly aimed at high-level drug manufacturers and distributors, analyses find that these prosecutions are most often leveled against friends of the descedents who were not selling significant quantities of drugs.

This criminalization is also spreading to rural areas and encompassing poor whites as well as people of color. An analysis of jail data suggests that in the past several years, jail populations have continued to grow larger in rural counties while they have declined in many large cities. Between 2004 and 2014, the percentage of white people in jail grew 19 percent in rural counties and 15 percent in small- and medium-sized cities. The focus on therapeutic responses to addiction for affluent and middle-class whites has not diminished punitive responses for black and Latinx as well as poor white people.

The opioid crisis is emblematic of larger shortcomings of the U.S. approach to complex public health and social problems.

For all these reasons, MAT alone cannot solve the opioid crisis. In a nation that has relied heavily on pharmaceuticals to solve everything from depression to erectile dysfunction, the notion of a simplistic magic bullet and technological solution to the complex social problem of drug use is culturally compelling. But until we address the root causes of problematic opioid use—including the racial capital that has warped our governance of markets for psychoactive substances—MAT alone is unlikely to succeed. We need also to address a lack of basic needs such as housing and income, as well as the social isolation and stigma that exacerbate use, especially in economically depressed communities. In the United States, of course, all of these are deeply rooted in structural inequalities of race and class.

The opioid crisis is emblematic of larger shortcomings of the U.S. approach to complex public health and social problems. As such, it provides a singular opportunity to address those shortcomings in our public health and social infrastructures. What the crisis has revealed, among other things, is our tendency to subsidize corporate systems of racial capital while—partially as a consequence—failing to invest in public health and health care systems, particularly in low-income communities and communities of color. Now is the time to leverage political awareness to create a meaningful anti-racist campaign for change.