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The Face Of Rural Addiction Is Not What You Think

7 minute read
Jerel Ezell is an assistant professor in community health sciences and the director of Center for Cultural Humility in the School of Public Health at the University of California, Berkeley.

If you were asked 30 years ago, at the height of the crack and heroin epidemics, what the typical drug user looked like, what would you say? You would probably say they were some combination of urban, poor, and Black or Latino. And you wouldn’t be too far off.

But by the early and mid-2000s you might have noticed that drug use was seemingly becoming more common outside of the nation’s impoverished, non-white inner cities. This was when pharmaceutical companies began to be prosecuted for deliberately misleading clinicians and patients on the benefits and risks of pain medications, like Oxycontin and Vicodin. And it was when the media began to take notice of how the social scourge of drugs had “finally” caught up to Middle White America, and began to focus on the drug-fueled struggles of white people. In less than a decade, the vision of the modern drug user became white, and the narrative around drugs changed. No longer were drug users criminals and lost causes—now they were redeemable and in need of medical and social support. In 1995, 18% of Americans admitted they had drug use issues in their family, according to a Gallup poll. In 2021, that percentage surged to 32%, punctuating how much closer to home the drug epidemic—no longer a fringe, sensationalized issue—was becoming for the average American.

Hollywood's embrace of white drug users

Hollywood execs took notice of these trends and began to invest in America’s newest pain points, with Emmy-winning TV series like Breaking Bad and Hulu’s Dopesick reinforcing the disingenuous trope of the opioid crisis as a white crisis.

Yet, while America has finally digested the idea that “hard” drug users can be white, the real, not-so-new face of addiction is a Black one. But it’s not the Black drug users you’ve seen on The Wire, or likely anywhere else on screen. The new face is rural Black people. Ones who work as farmers and landscapers. Ones who live in communities where dollar stores serve as the center of commerce and community. Once viewed through a very narrow—and racialized—lens, the drug-using population in America has become more of a melting pot than America itself—eclectic and deeply and often precariously interconnected. 

While rural areas in the Deep South have always had large Black populations owning to its centrality in the slave trade, in the last two decades, other rural communities in the U.S., particularly the Midwest and Northeast, have been diversifying. Nearly a quarter of rural Americans now identify as people of color. In part due to the clunky and inconsistent ways that the federal government defines “rural,” the rural Black drug user has largely been invisible to researchers and interventionists. And it’s not just opioids like heroin afflicting the population, but stimulants like crack and methamphetamine (usually seen as a “white drug”), which are cheaper and prolong highs.

Read More: Drug Overdose Deaths Rose More Among Black and Indigenous Americans During COVID-19 Pandemic

Our team of researchers—from Cornell University, Southern Illinois University, and University of Chicago—conduct research with rural Black opioid users in central New York and southern Illinois, two areas of the country with persistent opioid overdoses. Most, but not all of our Black participants are middle-aged men, with roots or connections to larger nearby cities like Chicago and New York City. Most of them or their families were at some point priced-out of the larger, hyper-competitive city life, and now have minimal prospects for upward mobility—but at least an opportunity for affordable housing and some semblance of peace. This isn’t always what they find.

Rural Black people have the highest poverty rates among rural residents, at 30% vs.12% poverty among rural whites. Rural Black people also have higher rates of mental illness, cardiovascular disease, cancer diagnosis, and sexually transmitted infections. In addition, they experienced disproportionate patterns of COVID-19-related deaths, highlighting the all-encompassing ways that rural Black people are both socially and medically vulnerable.

Rising overdoses in Black Americans

While researchers have increasingly recognized opioid use disorder as equal opportunity, rural Black people have represented, at best, a blip on epidemiologists’ radar. This is changing. One study found the steepest increase in overdoses in recent years has been among younger urban Black Americans (178%), followed by younger rural Black Americans (98%) and then younger urban white Americans (93%). And while rates of opioid use disorder are generally higher among whites, overdose deaths have increasingly been higher among Black individuals; in short, when Black people overdose, they’re more likely to die from it than white people. And this effect is even more pronounced in rural areas, where access to emergency services still lags far behind suburban and urban areas in the country.

In these communities, Black drug users are no more a medical anomaly than white drug users, and yet due to the low density, they can’t help but stand out. As Luke, a 25-old Black man in our study explained, “Everybody knows everybody. And that's the biggest thing that's different. So, you got to make sure you're on your P's and Q's and doing what you're supposed to do because everybody can see you.” (Luke asked us not to use his real name to protect his privacy). It’s this simultaneous visibility and invisibility that makes life for rural Black drug users especially intricate, driving higher rates of isolation, which is perfect kindling for initiating drug use and overdosing without social support.

Along these lines, key factors that drive and sustain disproportionately high-risk drug use among rural Black people include the limited socialization and recreation opportunities in rural areas, and a predominance of physically-intensive jobs in farming, manufacturing, construction, and mining, where workplace discrimination and social isolation are high. Further, government neglect is implicated in the crumbling infrastructure and low-quality housing that characterizes rural Black areas. In a nutshell, it’s these additive components that increasingly propel and deepen hazardous drug use patterns in these communities.

Vulnerable populations

A variety of other dynamics make rural Black communities especially vulnerable. This includes high levels of stigma against drug use, prohibitive policies against medications for opioid use disorder like suboxone and methadone, which are effective in helping drug users manage their symptoms and taper off usage, and, relatedly, restrictions against public benefits such as Medicaid– typically states with the highest rates of rural overdoses have rejected expansion under Obamacare. Rural communities also have substantially less access to naloxone, a vital tool in efforts to reverse overdoses that was recently approved for over-the-counter sales but remains expensive for the average rural consumer (and is dispensed at stores that may not be common in their communities). In brief, the issues are broad and wide, yet hiding in plain sight. 

There are no easy answers to the question of how to address the complex challenges facing rural Black drug users. Would an increase in resources—healthcare clinics, mental health services, naloxone, and suboxone—help? Of course. But unless the underlying issues that ultimately create and sustain risks in this population are addressed—the racism and classism in and around rural areas that serve as a microcosms of core, ongoing issues in the U.S.— it’s all for naught. To that end, the one critical resource that cannot be cultivated through policy is empathy. But as a start, as we continue to think about the “two Americas” that exist, one for whites and one for the non-whites, we can at least push ourselves to more thoughtfully consider geography in that equation.

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