Now that we have clarified how our understandings of drug use and harmful drug use are socially constructed, we can explore how differences in social location can influence when drug use is considered problematic and how outcomes may differ. For this section, we will specifically consider geographic location and race and ethnicity to look at the inequality in outcomes.

8.3.1 The Opioid Crisis and Geography

The opioid crisis of the late twentieth and early twenty-first centuries opened many people’s eyes to the idea that people were using so-called harder drugs (such as heroin) outside of cities. Sociologists use the term urban to refer to cities.

Before this, institutional racism within our government, drug policy, law enforcement, and the media made it appear that most users of heroin were poor BIPOC living in urban centers. The government also supported this image, because it supported racist beliefs, and removed power from Black and Brown people. This perspective is explicitly stated by John Ehrlichman, Assistant to the President for Domestic Affairs under President Richard Nixon, 1994:

You want to know what this [war on drugs] was really all about? The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: the antiwar left and black people. You understand what I’m saying?

We knew we couldn’t make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news.

Did we know we were lying about the drugs? Of course we did (Vera Institute).

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The release of Oxycontin (an opioid-based pharmaceutical painkiller) in 1996 and its widespread use eventually came to be known as the opioid epidemic.. Some sociologists disagree with the use of epidemic to describe this social problem because it implies that opioid use can spread like a virus and imagines users of opioids as infectious people. Instead, a more accurate description of the problem would be the opioid crisis, which refers to the surge in fatal overdoses linked to opioid use (DeWeerdt 2019).

The opioid crisis began with the over-prescribing of opioid-based painkillers, causing some individuals to become physically dependent. When individuals lost access to the prescribed painkillers, some people started to use heroin, another type of opioid with the same effects on the body.

The opioid crisis alerted Americans to the existence of opiate use in rural and suburban areas by White populations. Most research on drug use up to this point had been conducted in urban areas. The opioid epidemic launched new research into areas outside of cities, including suburbs, those communities that surround a city, and rural areas, with fewer than 2,500 people. With the opioid crisis affecting an estimated 10.1 million people in 2019, sociologists wanted to understand how drug use might differ by geographic location.

Figure 8.3 Anthropologist Angela Garcia

Anthropologist Angela Garcia, shown in figure 8.3, spent several years researching heroin use among members of a Latinx community in rural New Mexico. Her findings point to the loss of a connection to land and livelihood and the experience of settler colonialism as social determinants of harmful heroin use (2010). Settler colonialism, as we explored in Chapter 5, is a system of power that normalizes the continuous settler occupation of Indigenous lands and exploitation of Indigenous resources. It is eurocentric in nature and assumes that European White ideas and values are superior (Cox 2017).

Garcia’s (2010) research found that dispossession of ancestral lands ruptured the link to cultural heritage and caused impoverishment. Together the disconnection and poverty formed a source of never-ending emotional pain for users of heroin. The sparsely populated rural setting also meant that drug treatment was less available. By examining the history of dispossession and oppression that impacted this community, Garcia (2010) shows how the social determinants of harmful drug use can illuminate the root social causes of the problem. In Angela Garcia on “Postcolonial theory and psychological anthropology” [Vimeo Video], Garcia discusses her relationship with the families that she studied with.

8.3.2 Drug Use in Black Communities

Figure 8.4 Cocaine with the tools to use it. How might the laws around cocaine usage be enforced differently based on race?

A sociological perspective can point us toward ways that social oppression based on race might correlate with harms caused by drug use. Research documents the relationship between experiences with racism and illicit drug use among Black women (Ehrmin 2002). This research shows that while socioeconomic class was a factor it was not the sole determinant of drug use (Stevens-Watkins et al.2012). Instead, a stronger ethnic identity and more community cohesion were found to be associated with less drug use among Black women (Maclin-Akinyemi et al. 2019).

Substance use can lead to worse outcomes, such as arrest and incarceration, among certain populations based on their position within structures of oppression. For example, the ramped-up War on Drugs in the late 1980s in response to the so-called crack cocaine epidemic resulted in the incarceration of a vastly disproportionate number of Black people (Hart & Hart,2019; United States Sentencing Commission 2002). As we remember from Chapter 6, mass incarceration strips groups of people of basic civil and human rights. These rights include the right to vote, the right to serve on juries, and the right to be free of legal discrimination in employment, housing, education, and basic public benefits. Economically, incarcerated people experience gaps in employment resulting in lower lifetime wages (Alexander 2010, as cited in Sanchez et al. 2022).

Black people who use drugs receive inequitable treatment for drug use when compared to White people. The opioid crisis provides an example. The societal response to opioid use and dependence among White people during this crisis has been gentler, relying more on treatment than the criminal justice system (Hart & Hart, 2019; James & Jordan 2018). According to statistics from the Bureau of Justice, 80 percent of arrests for heroin trafficking are among Black and Latinx people, even though White people use heroin at higher rates and are known to purchase drugs within their own racial community (James & Jordan 2018).

Differences also exist in treatment options. White people who use opioids have been given more access to the preferred addiction treatment medication buprenorphine (which requires periodic visits to a private physician) compared to methadone, which requires near-daily trips to a clinic. Treatment with buprenorphine is less stigmatized because it is dispensed like any other pharmaceutical medication at a private doctor’s office As mentioned, methadone requires frequent visits to a methadone clinic. Often BIPOC receive treatment at the less-preferred methadone clinics (Hansen 2015). Politicians legalized Buprenorphine treatments for opioid use disorder, supporting the privileged lives of middle-class White addicts (Netherland & Hansen, 2017).

Worse health outcomes from substance use, such as HIV, are more prevalent among Black people who use drugs due to structural inequality (Des Jarlais et al. 2012; Kottiri et al. 2002). Black people who use drugs often reside in racialized risk environments. Risk environments are spaces—whether social or physical—in which a variety of factors interact to increase the chances of drug-related harm (Rhodes 2002). These environments may have less access to drug treatment programs or sterile needles. Police surveillance may occur more often. These risk environments may also be racialized. In the words of public health researcher Hannah Cooper and her co-authors:

A risk environment is racialized when racial/ethnic groups of [People Who Inject Drugs] PWID inhabit places that differ systematically in the availability of protective features (e.g., substance abuse treatment programs) and in the presence of harmful features (e.g., police drug crackdowns). (Cooper et al. 2016)

These risk environments lack access to sterile injection equipment (e.g., through purchasing new syringes over-the-counter) and drug treatment programs. They have less economic advantage, and more police surveillance.

These characteristics of the social landscape contribute to increased health harms, such as contracting HIV or hepatitis C, for Black people who use drugs. Health harms caused by substance use are higher among Black people who use drugs, not because they participate in riskier drug use behavior, but because they reside in under-resourced communities that hinder access to health-promoting services and materials (Cooper et al. 2011). Accordingly, opioid overdose rates for Black people have historically been higher than those for White people in some states. Recently this rate has been increasing more rapidly, though the media attention surrounding the opioid crisis mostly focuses on drug use by White people (James & Jordan 2018).

8.3.3 Drug Use in Indigenous Communities

Indigenous people report the second highest rate of illicit drug use disorder in the past year at 4.8 percent (for the period from 2015–2019). The highest percentage is among people who identify as two or more races or ethnicities. Indigenous people are also the highest percentage of people who sought treatment for illicit drug use disorders and received it (Center for Behavioral Health Statistics and Quality 2021).

Figure 8.5 Researcher Maria Yellow Horse Brave Heart, of the Hunkpapa/Oglala Lakota

 The work of researcher and professor Maria Yellow Horse Brave Heart, shown in figure 8.4, explains how the historically-based trauma experienced by Indigenous communities in the United States may impact substance use. She emphasizes that the traumatic losses suffered across generations by the North American Indigenous populations meet the definition of genocide. She lists massive traumatic group experiences as part of the intergenerational trauma experienced by this community, which may contribute to substance use (2003:8).

This list includes traumas such as massacres; prisoner of war experiences; starvation; displacement; separation of children from families and placement in compulsory and often abusive boarding schools; disease epidemics; forced assimilation; and the loss of language, culture, spirituality. All of this contributes to the breakdown of family kinship networks.

In the video “Historical Trauma in Native American Populations,” she talks about her work understanding generational trauma. She points to an 1881 U.S. policy outlawing the practice of Native ceremonies, which prohibited traditional mourning practices. This undermined practices of healing and resolution that might improve wellness and potentially lower problematic substance use levels.

Urban Indigenous people who use alcohol and/or other illicit substances reported symptoms of historical trauma (Wiechelt et al. 2012). Brave Heart (2003), points out that alcohol was not part of Indigenous culture except for in specific ceremonies before colonial contact.

Researchers suggest that treatments for substance use disorder among Indigenous peoples should coincide with decolonizing practices. This means that Indigenous communities should be supported in making attempts and achieving control of land and services. Nutton and Fast (2015) report that:

communities that have made attempts to regain control of land and services have been found to have lower suicide rates, reduced reliance on social assistance, reduced unemployment, the emergence of diverse and viable economic enterprises on reservation lands, more effective management of social services and programs, including language and cultural components, and improved management of natural resources. (Chandler & Lalonde 1998; Cornell & Kalt 2007)

Identity formation can also be a helpful part of drug treatment for Indigenous individuals. Research indicates that increased participation of Indigenous peoples in their culture of origin can decrease the prevalence of substance use disorder (Nutton & Fast 2015).

Finally, all drug treatment interventions should be culturally adapted for Indigenous communities. For example, among Indigenous inhabiting the Plains, the Sun Dance was performed in thanksgiving for a bountiful year and a request for another year of food, health, and success. Today community members will pledge to do the Sun Dance to maintain their sobriety from alcohol or drugs.