Does the world really need another book that examines the opioid-involved overdose crisis? There’s no shortage of tomes devoted to deconstructing, badly or (rarely) well, what happened.

The answer is an unequivocal yes, when it comes to Whiteout: How Racial Capitalism Changed the Color of Opioids in America (University of California Press, 2023), by Helena Hansen, David Herzberg and Jules Netherland. Through a critical lens of racial capitalism, the authors dissect licit and illicit opioid use and access, from past to present.

In the first chapter, “Pharmakon of Racial Poisons and Cures,” Hansen lays out their thesis: “We examine the unspoken but determinative Whiteness of opioids, to make the ways that Whiteness works in drug policy and treatment visible. Here, whiteout refers to the use of imagery to hide or cover the inner workings of segregation in drug policies and healthcare industries.”

You’ll find sentences that need underlining on every page. 

The authors present an original analysis that will persuade many readers to reevaluate their beliefs about the intersection of Big Pharma, drug prohibition and for-profit health care. For example, in the chapter “Oxycontin’s Racial Precision” they write, “Purdue Pharmaceuticals’ betrayal turns out not to be about the betrayal to all consumers; rather, it is about the breach of an implicit promise to uphold a safe, affluent white zone of clinical narcotic consumption, segregated from illegalized and hazardous racially ‘other”’street markets.” Bam! This provocative assertion should trigger many debates.

Whiteout is written by three uniquely qualified individuals whose research and writing overlap. As a result, the book includes an astonishing amount of material backing up their assertion that Whiteness is foundational. You’ll find sentences that need underlining on every page. Their recent webinar, moderated by historian Robin D.G. Kelley and sponsored by Haymarket Books and the Drug Policy Alliance, is also recommended viewing.

Jules Netherland is a sociologist and policy advocate. Her experience ranges from working in a soup kitchen with Franciscan monks to buprenorphine researcher to policy advocate. Her harrowing account of what it took to pass a stripped-down medical marijuana bill that would help few patients is required reading. It’s an illuminating example of the power of Whiteness to shape drug policy even when anti-racist activists fight hard to prevent it. Netherland writes, “The entry of suburban moms and their children changed the debate and what was possible for medical marijuana legislation …’white innocence’ seemed to be what legislators and the media found most moving.”

David Herzberg is a historian who writes, “Remembering forgotten things is what historians do.” Among his many contributions to the book is explaining how Whiteness has always influenced access to opioids. From Chinese opium use to the era of Jim Crow to today, he unpacks the “racialized drug/medicine divide.” He includes striking side-by-side quotes from politicians, police and pundits that reveal almost every era has had a prescription drug crisis. We just forgot.

Hansen is an addiction psychiatrist and anthropologist. She is an astute observer and interviewer. And her experience working inside opioid treatment programs provides invaluable insight through her witnessing of the effects of Whiteness in real time. Her hilarious story about a white buprenorphine patient from Long Island speaks volumes about privilege: “She pulled her car into the taxi stand at the hospital entrance and called the clinic staff from her cell phone. ‘I’m right downstairs and there is nowhere to park. Could you just bring down my script?’ No one ever did.”

Dr. Hansen spoke with Filter about the system of Whiteness, and its pernicious impacts on health care and access to lifesaving medication.

 

Helen Redmond: In your book, you discuss your experiences working in a New York City public hospital, with a compelling analysis of race, class and medication for opioid use disorder. Can you tell us about who gets prescribed buprenorphine and who goes to a methadone clinic?

Helena Hansen: So first, I’ll describe the cognitive dissonance when I went to the methadone clinic, which was a requirement of anyone training in addiction medicine or addiction psychiatry. The methadone clinic was everything you might expect of a New York City public hospital. We had a bunch of underinsured, publicly insured and uninsured patients, many of whom were referred to the clinic by drug courts and parole officers. So they were mandated to treatment in many cases.

A lot of them had unstable housing. And it was clear that the clientele was primarily Black and Brown, and any white patient who happened to get into the mix was clearly down on their luck.

It was the kind of clinic that had signs with all of the rules posted everywhere. There was a lot of enforcement of rules, security guards right at the front of the line with separators and dividers to keep everyone in check. The nurse was behind bulletproof glass. Patients would have to take methadone in front of the nurse, who would inspect their mouth right after swallowing it to make sure they were taking it—meaning not hiding it in their cheek to sell on the street afterwards.

“The contrast was remarkable. I began asking, how did this happen? These are patients that supposedly have the same clinical disorder.”

I would sit there and observe people taking their methadone doses. There was unannounced urine testing. The person had to be accompanied by a same-sex security guard or staff member, to make sure that they weren’t sneaking someone else’s urine into the sample bottle. It was highly controlled and had a carceral feel. It just didn’t feel like it was a health care space.

That was in sharp contrast to the brand-new buprenorphine clinic that I saw get started. This was just after buprenorphine had been approved by the FDA for office-based treatment of opioid use disorder. It was fascinating to see the clientele that the clinic attracted; it was largely white. They were people who had graduate degrees, who had really nice kinds of jobs—journalists and managers. They were people who you would not find in any other clinic in a large city public hospital.

The contrast was really remarkable. That’s what actually tipped me off and led me down this path that became a partnership with Jules Netherland and David Herzberg. I began asking, how did this happen? These are patients that supposedly have the same clinical disorder.

I began to pay attention to how people learned about buprenorphine, and how they got referred for it instead of methadone. And even though these two clinics were in the same building, two floors away from each other, they were two completely different worlds. The people coming to the clinic had gone online and done their research about where to find buprenorphine. They’d learned about it through internet ads or a private doctor. These people were really educated, really well-connected, and some had private insurance. They were in a totally different league.

 

How do you define Whiteness and how it operates? 

What I mean by Whiteness—my coauthors and I use the term much more often than we refer to white people—is that Whiteness is more than the color of someone’s skin. Whiteness is a whole system.

If you find yourself in a system like this, it doesn’t matter whether you claim to be a white person or not, you’re falling into a system that has implications that are beyond your control.

“Systems of Whiteness, we argue, are harmful to everyone.”

For instance, I’m not somebody who, if you were to look at me, would be considered white. And so I cannot just declare myself to be white and get so-called benefits of Whiteness. But neither can someone who could claim to be white, based on their heritage and their appearance, decide, “I’m unilaterally going to just not do anything that takes advantage of my white status in society.”

Whiteness is a social system by which people are regulated and channeled into a health care system that is stratified. Systems of Whiteness, we argue, are harmful to everyone.

I began to track Whiteness and how that works within our health care system and within pharmaceutical marketing. In interviewing pharmaceutical executives and addictions researchers, I discovered that historically, the way office-based buprenorphine evolved was when federal legislators and pharmaceutical executives started paying attention to the approval of Oxycontin for use in moderate pain in 1996. They were tracking the evolution of a whole new group of people who were dependent physiologically on opioids and who, in their minds, weren’t suitable for methadone treatment programs.

And you can actually find that language in the Congressional Record. They didn’t mention white people, but they referred to suburban youth and suburban communities. We know in the US that’s coded language for largely middle-class white people. So it is race and class bound together.

We realized that we were excavating a whole system of Whiteness within pharmaceutical development and marketing, and also in relation to drug policy and the health care system.

“It was no accident that the buprenorphine clinic was so distinct by race and class.”

It involves pharmaceutical companies with the most expensive new products that are patented, so they have exclusive rights to sell that product at whatever price the market will bear. Usually the initial clientele is a white, middle-class-to-affluent clientele that can buy the medication.

It was no accident that the buprenorphine clinic was so distinct by race and class. It was originally designed for people who could pay with private insurance or out-of-pocket. The last national study showed that white Americans were three-to-four times as likely to get buprenorphine as Black Americans, and the most common form of payment was out-of-pocket, followed by commercial insurance. And it’s very, very thinly veiled in the Congressional Record when they were debating legalizing buprenorphine for office-based treatment.

They managed to get federal law passed that reversed 80 years of federal prohibition of private doctors prescribing opioids to people dependent on opioids for addiction treatment. Since 1914 and the Harrison Act, there have been a lot of federal laws that have strongly discouraged and then prohibited doctors from doing that.

Methadone maintenance was just a very partial exception. It was this moment in the late ‘60s, early ‘70s, when in the midst of race riots and white flight from center cities, there was a perceived heroin problem. Methadone was one of the things Nixon rolled out in the War on Drugs. Methadone was a way to pacify or address that, in addition to arrests and incarceration. So it has this whole other racial biography.

 

How did Purdue Pharma’s marketing of Oxycontin intersect with Whiteness?

Purdue Pharma, they were just doing good capitalism and delivering for their shareholders as promised. They’re trying to market a product, so that’s where Whiteness comes in. It’s not just any individual person’s status as a white person, it’s actually a system that many of us are forced to participate in.

With regard to selling Oxycontin, they knew who their clientele was. They knew that they were going to be selling a very expensive product, and the people who were going to buy that product would have nice private insurance or be able to pay out-of-pocket.

There was a subset of working-class people with workers comp. insurance that would pay for these new opioids. So I want to make it clear that from the get-go, there was a sub-group, particularly the laboring classes in construction and mining, who had insurance that would pay. Purdue Pharma was also looking for people who did work that left them with a lot of injuries and needed treatment for pain. So from the beginning, it wasn’t only affluent people.

They also knew that they were going for deregulation of an opioid in a society that has had incredibly prohibitionist policies for a century. And they knew that one reason for those strong prohibitionist policies had been the non-white races [to which] the media and politicians had been attributing addiction for a century. So they knew that the white color and relative affluence of their clientele would be a helpful antidote to push deregulation of an opioid in a very drug-phobic society.

“The political compromise in the 1990s was not to expand disability benefits for people in pain, but to allow the private market to be liberalized.”

My coauthor David Herzberg really adds nicely to this, which is that there was a whole politics of pain happening at the time. It’s no accident that in the 1990s, there was an epidemic of pain declared. And there were a number of organizations, starting with the VA hospital system, that were calling attention to the under-treatment of pain.

At the same time there’s also a raging political struggle around Social Security disability benefits. So left-leaning people wanted to liberalize benefits and be much more cognizant of pain as a source of disability, and free up more public resources to support people who are disabled by their pain—versus right-leaning people, who did not like the idea of expanding public benefits and saw a danger of indulging too many “welfare queens” who were claiming to have pain.

So the political compromise in the 1990s was not to expand disability benefits for people in pain, but to allow the private market of treatment for pain to be liberalized, including the new opioids. That’s the role Whiteness played early on in the politics of opioid marketing. Not only did they know who their market was, who could afford it, they also knew how to get around the regulations and take advantage of the privatization of the pain problem.

 

Rep. Donald Norcross (D-NJ) has a bill called the Modernizing Opioid Treatment Access (MOTA) act. It would allow patients to pick up methadone at a pharmacy—bypassing the clinic system, which Norcross calls a cartel. But I have a serious problem with the fact that MOTA only allows board-certified addiction physicians and psychiatrists to prescribe methadone. In line with your analysis, it seems that white middle-class people would be able to escape the carceral clinic system—because of Whiteness. What do you think?

I think you said it beautifully. I mean, that’s exactly it, relying on the same tiny group that does buprenorphine prescribing to do methadone prescribing.

I’m an addiction psychiatrist. I know that there are very few of us, and that most of us are in private practice. I can name the number of Black addiction psychiatrists in the country on one hand. If you’re a hyper-specialist, you know who your clientele is going to be: You’re choosing a rich clientele, largely white, just by specializing. That’s what you get in a privatized health care system. So this is not a solution to the inequalities that we’re facing. It’s the same little exclusive group that currently gets buprenorphine that will pick up methadone at a pharmacy with this legislation.

You have to overhaul the way the system works. If Norcross is serious about equity, he would do what the people testifying at the NASEM workshop on methadone regulation last March were talking about. Put methadone into community organizations. If you want more LGBTQ people to have access to methadone, put it into LGBTQ community centers. You make sure that the kind of people those centers hire are able to prescribe it, that’s the way you do it. You don’t go to hyper-specialists.

 

Do you think that ending the drug war and legalizing and regulating all drugs would eliminate racial disparities in drug treatment?

That’s a really nice question. If what you mean by ending the drug war is that you legalize or at least decriminalize drugs, and have a way of regulating their quality, then I think that would help with overdoses. That would help a lot with the death rate we’re seeing that shot up among white Americans and got everyone’s attention a couple of decades ago, but now is evolving into a Black and Brown overdose problem. I think that overall, you’d see less drug deaths because the supply would be safer, it would be regulated.

With regard to treatment, I think that’s a separate and related question. If you legalize and regulate substances without addressing the fact that we don’t have universal health care, we have an extremely race- and class-stratified health care system, any kind of treatment that’s going to be delivered through this system is just going to be stratified.

If you see countries where they’ve had a lot of success with opioid maintenance treatments, France is one I often turn to as an example. My colleagues, who are big buprenorphine advocates, point to France and say, “Look how they lowered their overdose death rates by 80 percent within the first five years of introducing primary care based buprenorphine.”

“If we want French-style results, we have to use French-style techniques. It’s not just buprenorphine, it is also investing in social services.”

They leave a lot of things out of the picture. The fact is, not only does France have universal health care, buprenorphine was not introduced as this private-market, white-exclusive thing, which it still is in the US. From the very beginning it was low-income, largely immigrants who were the anticipated recipients of buprenorphine treatment.

The French also invest twice the amount of money per capita as we do in social services. They bundle up opioid maintenance treatment with social services in community-based addiction treatment centers, where they have peer navigation and housing and employment assistance. It’s just a very different system.

So if we want to get French-style results, we have to use French-style techniques. It’s not just buprenorphine, it is also investing in social services and in people with lived experience working in community-based centers.

That’s why I don’t think that eliminating the drug war, although that would be fantastic, would solve a lot of problems that contribute to racial inequalities, including mass incarceration. We have to address the lack of universal health care and the need for social service investments.

 

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Detail from cover of Whiteout: How Racial Capitalism Changed the Color of Opioids in America via University of California Press. Inset photograph of Helena Hansen courtesy of Dr. Hansen.