Editor’s Note: This interview first appeared in Path Finders, an email newsletter from the Daily Yonder. Each week, Path Finders features a Q&A with a rural thinker, creator, or doer. Like what you see here? You can join the mailing list at the bottom of this article and receive more conversations like this in your inbox each week.
Helena Hansen is a psychiatrist, anthropologist, and professor at the University of California, Los Angeles’ David Geffen School of Medicine. Her recent book “Whiteout: How Racial Capitalism Changed the Color of Opioids in America,” written with co-authors Jules Netherland and David Herzberg, covers the whitewashing of the opioid epidemic and its lethal consequences for all Americans.
Enjoy our conversation about the geography of methadone, the “decade of the brain,” and the biosocial model of addiction, below.
Olivia Weeks, The Daily Yonder: Let’s start with your bio, and then we can talk about how your medical practice led into this book.
Helena Hansen: Essentially, I was in college and graduated from college in the late 80s and early 90s, just around the time of the AIDS pandemic. So my whole worldview as a young person was shaped by all of the fear and all of the deaths and then the political mobilization around the AIDS pandemic. That really shaped my whole view of the world and what I wanted to do with my life, so my first real job out of college was working for the National AIDS Fund, which was designed to support grassroots community organizing around AIDS and to get more resources for HIV prevention and treatment.
It was very clear that race, class sexual orientation, and also drug use status were huge factors when it came to HIV not getting the kind of national response that you would expect a pandemic to get. So I ended up working with people who use drugs in inner-city New Jersey. And that really influenced my view of how medicine misunderstands communities and what they need. I was inspired by models that started to integrate community members into decision making about health care. I also was really inspired because, in doing that, federal policy was changed. There were new regulations due to grassroots HIV activism that the National Institutes of Health (NIH), for example, had to put HIV-positive people on their decision making councils.
That paradigm shift inspired me to jointly train in medicine and in anthropology with a focus on community research. And it also led me to specialize in addiction and to pay a lot of attention to the intersection of drug policy with class race, gender, and other forms of social hierarchy and marginalization. So that’s how I got focused on addictions and drug policy. And then when I was training as a medical student, I heard about this new medication called buprenorphine, otherwise known as Suboxone. My teachers in medical school said it was going to revolutionize the field of medicine by getting doctors to treat addiction just like any other chronic illness, like diabetes or hypertension or asthma.
And then I began to observe that there are these deep divides with regard to race and class as to who was getting access to buprenorphine and how they were treated. And to some extent, it also panned out along the lines of rural versus urban. Certainly people who are either urban or suburban and had good insurance or the money to pay out of pocket were the ones getting this treatment, and those who were rural or in inner cities without access to healthcare providers and good insurance didn’t have any access to it. That led to the research that I published with my co authors Jules Netherland and David Herzberg just this spring. “Whiteout” is about race and class, and it’s about low-income rural residents who’ve been left out of this model of doctor’s office treatment for addiction.
DY: Can you tell me about the particular history of buprenorphine and its predecessor, methadone, and how that history played out along those racial and class and geographical lines?
HH: In the 1990s we were in “the decade of the brain” as it was declared by the first President Bush, in which NIH and federal agencies were really directed to look for molecular and biological causes for problems like addiction. It was a very brain disease-focused model. The director of the National Institute of Drug Abuse at that time, Alan Leshner, publicly redefined addiction as a chronic relapsing brain disease. The idea was to fold addiction, along with a lot of other health problems, into something that could be cured with a molecule, or with the right medication. We no longer had to think of it as some sort of messy, moral, social, and biological problem. It could be solved with a magic bullet.
This kind of thinking was coming out of the Human Genome Project of the 1980s, and the idea that, since we have the human genome sequenced, we can really get to the molecular causes of just about any health problem. The thinking went that that would lead to a huge economic boom in the United States, because pharmaceutical companies and biotech companies would be able to take advantage of that new data to come up with these molecular magic bullets. So that was the setting for the manufacturer of the first extended release formulation of opioids, Oxycontin, to get rapid FDA approval. The idea was that they were able to biotechnologically solve the problem of the addictiveness of a strong opioid. That was the Holy Grail. The idea that a molecular biotech solution existed for just about every problem was really in the air in that decade. That idea created a lot of emphasis on deregulating pharmaceutical markets. There was a general desire to get things approved quickly to enable the pharma industry to move forward.
In that era, the race and class of the imagined consumer was an affluent white person. That’s who was represented in all of the marketing materials, and it was also consistent with the fact that expensive, newly patented medications generally can only be paid for by an affluent, largely white clientele. So people who were thought to be at low risk for addiction were really the intended clients. And then another clientele that was aggressively marketed to, even though they weren’t pictured in the marketing materials, was working class people often in rural areas who worked in industries like mining and construction, who had relatively good insurance for workers comp for pain complaints. That is why, across the country, there was a very quick increase in prescription of those newly patented opioids in the late 90s and early 2000s in suburban, largely affluent white neighborhoods, but also in rural places with working class people who had workers comp.
And then here enters buprenorphine: up until the late 1990s there was only one way that you could get an opioid maintenance treatment for opioid addiction that would stave off your withdrawal symptoms, making it so that you wouldn’t be tempted to go out to buy opioids on the illegal market or take them non-medically. That was through methadone clinics. Methadone clinics had been created in the early 70s as a major weapon in President Nixon’s War on Drugs, at a time when the media was concerned about two different heroin-using groups: people living in inner cities, and returning Vietnam veterans. Inner cities in the U.S. in the midst of race riots were depicted as places where heroin markets were really active. Somehow heroin had to do with the race riots, and all of the tensions that resulted from Black and brown people being twice as likely to be unemployed as white people. There was a lot of concern about those groups, and methadone was introduced as a solution to those problems.
Methadone clinics often look a lot like jails. They’re located away from the parent clinic in the neighborhoods that would have them. There was a lot of very stigmatizing “not in my backyard” politics around the placement of methadone clinics. And the way that people are treated in these clinics are very restrictive. The DEA has to oversee methadone clinics, they survey the prescribers, and the people who work in methadone clinics have to be specially certified. So it’s a very restrictive and kind of criminalizing environment that is related to the clientele. Basically, this was a treatment system that was really designed for Black, brown and white working class people.
So fast forward to the late 90s, in response to the outcomes of that aggressive opioid marketing campaign I just described, the big question became “how do we handle this suburban opioid crisis?” And when you read the Congressional Record, they talk a lot about methadone clinics, which had been stigmatized and marginalized for a long time, not being appropriate for this “new kind of addict.” That is when the idea of take-home prescription maintenance drugs was popularized. That’s when the system of buprenorphine treatment prescribed directly from any doctor’s office came about. Now, to this day, if you look at the statistics about who has access to buprenorphine and who gets methadone, it’s clear that they were successful in creating a two tiered treatment system, where affluent white people are treated quite differently than Black, brown or working class people.
DY: Wrapped up in this idea of a “new kind of addict” are these two theories, the brain-disease model and the deaths-of-despair model, that are both meant to destigmatize addiction. You write in the book about how these two models are actually quite contradictory, but sit together very peacefully in a lot of policy discussions. So it’s a very common refrain at this point that addiction is a disease and therefore addicts should not be blamed for their situations. And then, also, there’s this deaths-of-despair model, which is a more structural argument about the way that American life has changed, and conjures images of the white working class. I think that a lot of people might instinctively recoil at those two models being deployed at once. But I hadn’t read anything before about how those models actually contradict one another. Can you expand on that idea?
HH: I began to describe the roots of the brain disease model earlier, when I was describing the decade of the brain in the 1990s. The whole idea there was to convey that addiction is a problem that is rooted in these cells and molecules. It was saying that you can actually take the brain out of the body of the human being, and you don’t need to know anything about the identity of the person, their life experience, where they live, who they come into contact with. You don’t need to know any of those things in order to treat addiction, because the problem lies at the neuron level. You know, it’s a dramatically simplified idea of what addiction is and what it takes to treat a problem like addiction. And there’s a race and class story built into that because on the one hand, this is a universal model,so it doesn’t matter who you are, anyone in the world can be treated the same way. On the other hand, it erases identity. It erases the impact of class, poverty, race and racial discrimination, the kinds of neighborhoods people are living in, how exposed they’re going to be to illegal drug markets and all that goes along with that. It doesn’t want us to pay attention to those things at all. And so it got regulators and scientists and clinicians so narrowly focused on molecular solutions, as well as the kinds of people who would pay for those molecular solutions, that they forgot about the real world. Many of the true believer addiction researchers at that time were kind of ideological, they thought that if we redefine addiction as a brain disease that will take away the stigma. They thought that the brain-disease model was going to promote racial justice and push back against those negative images. And ironically, they only reinforced racial hierarchies in healthcare and in drug policy because they took away any attention to the social context and the hierarchies that people live in.
You also asked about deaths of despair. So interestingly, this deaths-of-despair idea didn’t come out until decades later, as a concept. For a very long time advocates have argued that if you pay attention to patterns of death and harm from drugs, you’ll see that generally the people who suffer the most are going to be people living in poverty and people experiencing racial discrimination. It’s not just biology, you know, any human being isn’t just randomly at risk for really bad health outcomes from substance use. Generally, it’s people living in very harsh circumstances that suffer the most. So why not pay attention to the circumstances? So there have been for many decades people doing research and making that argument but it hasn’t penetrated into American drug policy conversations.
That began to change in 2015 when two economists from Princeton, Anne Case and Angus Deaton, published a study that reported this surprising finding to many readers, that the life expectancy of white Americans had declined by about five years in the 20 year window that they were looking at, while the life expectancy of almost every other ethnic racial group, not including Native Americans, by the way, increased in that same time period. This was a big shocker in American media because, you know, we, this is a country where all of us expect white Americans to do better than Black or brown Americans. It’s a country where we’ve all grown up with a racial hierarchy that translates into different life expectancies, so to see a study that violated that expectation got a lot of media attention.
This was just before the 2016 presidential election, so there was already discourse in the air about working class white America being very dissatisfied. The intent of the authors was to call attention to the very dire living conditions of working class white America in Rust Belt towns, mining towns, and places where deindustrialization, the movement of labor to East Asia and cheaper labor markets had left behind large groups of people who are now unemployed at high rates.
They were able to get headline news because they looked at a very narrow window of time in which this finding was true, and they left out the period before and after, where Black and brown Americans’ life expectancy was still much lower than white Americans on average. You could also argue that the phenomena they’re studying, like deindustrialization, hit Black and brown communities much earlier, because generally working class Black and brown people were not allowed into many trade unions. So when jobs started to move overseas, they were the ones that were last hired, first fired.
In any case, they presented a different discourse that calls attention to economics and living conditions, which is quite different from this brain-disease model. But these two models both are quite racially embedded and serve different purposes. I’ve long argued that deaths-of-despair is a very good entry point to looking at root causes of addiction and the intervention that’s going to be needed, but it has to incorporate racial hierarchies and discrimination into it as well. If we don’t do that, we’re just going to reproduce those racial divisions by attending to working class white neighborhoods without paying attention to the deeply embedded racial discrimination and very, very long term disenfranchisement of Black and brown communities.
DY: It seems like one of the reasons that these things are allowed to coexist is the pithiness with which they can be conveyed. “Deaths of despair” really paints a picture. “Addiction is a disease,” as a catchphrase, really paints a picture. Is there a way of talking about addiction that you prefer?
What I’ve been pursuing with my colleagues is the idea of problems that are biosocial, meaning they’re both biological and social. They’re often social with biological consequences, which is, I think, the category addiction falls into. The early advocates of buprenorphine treatment argued for handling it the same way you would handle other chronic diseases like asthma, diabetes and hypertension. You want to get people suffering from those diseases to a doctor and get them on a maintenance medication.
That’s precisely what the buprenorphine treatment model is. In each of these health problems there are really huge social components.
Anyone who’s ever tried to treat diabetes, or hypertension or asthma, knows very well that you can’t just prescribe a medication and expect that someone will be able to continue to take the medication and then the problem will resolve fully with the medication. You have to make sure the person can afford the medication and continue to come to the doctor. You have to have access to fresh food. There are many neighborhoods in this country that don’t have stores that sell those things. You want to have regular exercise and walkable space outside of your house. There are many neighborhoods in this country where there are no such cases, either in dense cities, or in places where you have to be in a car all the time to get to where you need to go. So those are examples of how each of these problems is biosocial. And we need a health care system and an approach to public health that addresses the social as well as the biological factors involved in improving health outcomes.
This interview first appeared in Path Finders, a weekly email newsletter from the Daily Yonder. Each Monday, Path Finders features a Q&A with a rural thinker, creator, or doer. Join the mailing list today, to have these illuminating conversations delivered straight to your inbox.