
==== Front
Lancet Reg Health Am
Lancet Reg Health Am
Lancet Regional Health - Americas
2667-193X
Elsevier

S2667-193X(24)00202-3
10.1016/j.lana.2024.100875
100875
Correspondence
Structural racism: a fundamental cause of drug overdose disparities
Zhu David T. davetzhu@gmail.com

Medical Scientist Training Program, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
23 8 2024
10 2024
23 8 2024
38 1008753 7 2024
12 8 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
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pmcThe opioid crisis in the United States claims over 100,000 lives annually.1 Since 2013, widespread illicit fentanyl — often clandestinely mixed with other opioids and stimulants — has dramatically magnified racial/ethnic disparities.2 American Indian and Alaska Native (AIAN) and Black populations have been disproportionately affected, with rates of overdose deaths 1.8 and 1.4 times higher than their White counterparts in 2022.2 These alarming trends highlight the urgent need to address structural racism as a fundamental contributor to drug overdose disparities.

Structural racism manifests through entrenched discriminatory laws, policies, and institutional practices that systematically disenfranchise racial/ethnic minoritised populations, undermining their health and wellbeing. The fentanyl-methamphetamine syndemic demonstrates this vividly. Publicly available data from CDC WONDER between 2017 and 2022 reveals a surge in fentanyl-methamphetamine overdose death rates, rising 13-fold among non-Hispanic AIAN individuals and 16-fold among Hispanic and non-Hispanic Black individuals, surpassing the seven-fold increase among their non-Hispanic White counterparts.1 Simultaneously, overdose death rates among AIAN individuals involving either fentanyl or methamphetamine increased seven- and four-fold, respectively.1

Through the lens of Fundamental Cause Theory (FCT),3 structural racism exacerbates vulnerability to polysubstance drug overdoses via three primary mechanisms. Firstly, it functions through perpetuating socioeconomic inequities, depriving minoritised groups of comprehensive risk-reduction education and addiction treatment.3 Notably, fentanyl's severe effects on respiratory depression and methamphetamine's stimulation of the cardiovascular system can exert immense physiological stress, often necessitating more intensive and costly care.4 AIAN, Black, and Hispanic populations — already grappling with higher poverty rates and limited access to medication-assisted therapy — are poised to see disparities worsen. Secondly, structural racism also functions independently of socioeconomic status, with historical traumas, everyday discrimination, residential segregation, hyper-incarceration, and other structural inequities converging to heighten the risk of polysubstance use and obstruct access to high-quality care.2,3 These factors often leave minoritised populations with no choice but to seek healthcare in under-resourced settings, ill-equipped to manage and treat the complexities of polysubstance use. Finally, structural racism perpetuates overdose disparities in reproducible ways — persisting despite shifts in intervening mechanisms, such as the ever-changing landscape of synthetic adulterants being mixed into polysubstance formulations at alarming rates.3

In advancing overdose prevention and treatment strategies, equity-centered principles are crucial to avoid widening the mortality gap. For instance, as FDA-approved treatments for cocaine and methamphetamine use disorders become available, evidence-based strategies to address overlapping structural barriers that currently hinder racial/ethnic minoritised and marginalized populations from accessing other essential medications, like naloxone and buprenorphine, are paramount.5

Recognising structural racism as a fundamental causative component of overdose disparities isn't merely a sociological theory but an evidence-based, pragmatic strategy to address the increasingly deadly polysubstance crisis and promote health equity.

Contributors

DTZ conceptualized, drafted, and revised the manuscript.

Data sharing statement

The data that support the discussion in this letter are openly accessible through the CDC WONDER database at: https://wonder.cdc.gov/mcd.html.

Declaration of interests

I declare no competing interests.

Acknowledgements

No funding was received for this work.
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References

1 Centers for Disease Control and Prevention Wide-ranging online data for epidemiologic research (CDC WONDER) multiple cause of death https://wonder.cdc.gov/mcd.html 2024
2 Friedman J.R. Nguemeni Tiako M.J. Hansen H. Understanding and addressing widening racial inequalities in drug overdose Am J Psychiatry 181 5 2024 381 390 10.1176/appi.ajp.20230917 38706336
3 Phelan J.C. Link B.G. Is Racism a fundamental cause of inequalities in health? Annu Rev Sociol 41 2015 311 330 10.1146/annurev-soc-073014-112305
4 Timko C. Han X. Woodhead E. Shelley A. Cucciare M.A. Polysubstance use by stimulant users: health outcomes over three years J Stud Alcohol Drugs 79 5 2018 799 807 10.15288/jsad.2018.79.799 30422794
5 Barnett M.L. Meara E. Lewinson T. Racial inequality in receipt of medications for opioid use disorder N Engl J Med 388 19 2023 1779 1789 10.1056/NEJMsa2212412 37163624
