Opioid Settlements, Big Pharma, and Racial Disparities in the Opioid Epidemic

Despite recent overall decreases in drug overdose deaths, racial disparities are persisting. This, coming against the backdrop of sweeping national opioid settlements, offers a reminder of the enduring potency of systemic racism in the face of what is otherwise a demonstrable public health success.

Over the past decade, state and federal officials have coordinated a torrent of civil lawsuits against primary facilitators of the opioid epidemic, namely juggernaut manufacturers of prescription opioids including Purdue Pharma (maker of OxyContin) and Johnson & Johnson, as well as pharmacy chains such as Walgreens and CVS. The trial outcomes have punctuated the degree to which the plaintiffs have been effective at drawing a causal link between the pharmaceutical industry’s actions and the resulting epidemic, but not in illuminating the deeply racialized consequences that have followed. Given courts’ longstanding patterns of enacting disproportionate sentences on Black, Indigenous, and Latino drug users and dealers, present-day judicial inattention to the racial elements of the epidemic is not altogether surprising.

In the health sciences, Big Pharma has rarely been theorized as an immediate systemic actor in the disproportionate opioid-related harms in racial/ethnic minority populations. This is largely because the addiction medicine field—and the fields of public health and medicine more broadly—has been wedded to a conventional, frequently racialized, view that individual-level behavior rather than structural forces dictate risk.

Systemic racism directly cultivates and entrenches economic disadvantage in racial/ethnic minority communities, and, as a byproduct, stokes diminished social mobility and adverse health outcomes in these communities. Big Pharma seized upon these fissures, helping to foment a substantially higher rate of overdose-related deaths among Black, Indigenous, and Latino populations, relative to white populations. Nevertheless, these populations have been conspicuously devalued in the calculus for determining national opioid settlements that support prevention, treatment, and recovery efforts. Thus far, these settlements have led major pharmaceutical companies to pay substantial sums—often in the billions—to state and local government entities, a reflection of both the scale of the crisis and the growing recognition of corporate responsibility in shaping public health outcomes.

For much of the 2000s, as the opioid epidemic grew, opioid marketing was overwhelmingly targeted to the white, upper-middle class. During this period, prescription opioid (mis)use was substantially higher among white individuals compared to other races. By the early 2010s, as federal regulations increased and sales to white customers concomitantly dipped, Big Pharma’s marketing practices shifted, becoming more common in racially mixed counties.

One investigation of internal documents, compiled by investigators at Johns Hopkins University and the University of California, San Francisco, revealed that during this period, Purdue had been persuaded by consultancy group McKinsey & Company to “diversify” by targeting “underserved” and other socially and medically vulnerable populations. This focus would put racial minorities—specifically Black people, a population that experiences high rates of disparities in pain diagnosis and treatment—right in Purdue’s crosshairs.

Moreover, Purdue was encouraged to be an “end-to-end” provider (i.e., providing opioids as well as MOUD). This playbook seems to have been adopted or embraced by other corporations in the Big Pharma fraternity, as evidenced by the industry’s direct or implicit leveraging of each resource. Big Pharma’s economic imperatives, in conjunction with those of healthcare insurers, forged an environment where medications for opioid use disorder (MOUD), such as buprenorphine and take-home methadone, have been less commonly available to racial minority patients relative to white patients, deepening patterns of misuse and relapse.

Toward the mid-2010s, the gap in prescription misuse rates between Black and White people had largely closed, due in part to the aforementioned treatment gaps—and despite clinicians being more likely to downplay and neglect racial minority patients’ pain and deny them opioid prescriptions due to unwarranted, racialized fears of these patients abusing them. When people cannot access these prescriptions — due to geographic barriers, a lack of financial ability/insurance, or a prescriber’s resistance —they often turn to heroin or fentanyl, cheaper opioids that are more potent and more likely to induce an overdose.

In many settlements—most notably those in states or cities with large racial minority populations, like Baltimore, Maryland, that have been hit especially hard hit by the epidemic—Big Pharma has summarily denied wrongdoing. In conceding early to avoid a protracted and likely unwinnable trial, Big Pharma has simultaneously been able to preempt the public scrutiny that would likely come from testimony about their actions and inactions in racially minoritized communities.

To this end, these racialized fault-lines have historical precedent. As the government and courts cracked down on the marketing and sale of tobacco in white communities in the 1970s, manufacturers began more vigorously pushing their cigarettes (namely menthol), cigars, and chewing tobacco to racial minority communities. These manufacturers used print and TV media, as well as cultural events as their primary engagement conduits. In the 1990s, a multibillion-dollar settlement was reached in response to the tobacco industry’s long-standing use of predatory marketing—an acknowledgment, at last, of the harm wrought by years of calculated public deception. However, there was scant focus on the disproportionate impact on, in particular, Black and Indigenous tobacco users in terms of the population’s disproportionate burden of linked cases of lung cancer, asthma, and chronic obstructive pulmonary disease. Moreover, only a small fraction of the tobacco settlement funds have been, or are being, used for prevention or cessation efforts.

In the last five years, roughly $56.9 billion in opioid settlements have accrued nationally. A substantial portion of these funds have gone toward expanding access to vital resources like naloxone and MOUD. However, a considerable amount has also been questionably spent; for example, funding law enforcement equipment and surveillance systems that echo punitive mechanisms undergirding the War on Drugs rather than address the opioid crisis’s root causes. Some government entities have even used settlement funds to backfill budgets. Furthermore, most awarded governments have lacked a cohesive, evidence-based strategy (or the requisite operational infrastructure) for optimizing the funds to address racial disparities.

Moving ahead, we should focus on allocating funds to target the socio-structural risk factors that have directly stoked the epidemic. In racial minority communities, the primary structural risk factor for initiation and relapse is recurrent exposure to racism (e.g., discrimination in education and employment, etc.), which attenuates mental health. Mental health, in turn, is further exacerbated by a lack of access to evidence-based mental health resources. At the point of drug use initiation, these structural limits extend to access to prescription monitoring programs and treatment, to support prevention, wellness, and coping. Funding for culturally informed interventions in these spaces, which currently we have a dearth of, is crucial.

Additionally, settlement funds should help address the immediate structural harms wrought from the racialized opioid crisis, namely community disorder and disinvestment, that serve as incipient environmental risk factors. We should specifically focus on bolstering early education, workforce development programs, and new, quality housing, in at-risk communities, in addition to beautifying neighborhoods. In closing, these combined approaches offer us an opportunity to get upstream of the crisis vis-à-vis prevention, rather than focusing purely on managing downstream consequences as has been the field’s tendency.

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