After a troubling spike that began in 2019, the total number of drug overdose deaths dropped in 2023, according to data from the Centers for Disease Control and Prevention. Most of these deaths were related to opioid use. Despite the drop, steep racial disparities in opioid deaths, particularly among Black people, remain. Why? In part, these disparities persist because of what I and others believe is big pharma’s heavy but subtle racialized influence on the opioid epidemic.
Yet as these industry players continue to reach legal settlements with states and municipalities across the country, the courts have ignored their role in exacerbating the opioid epidemic in Black communities. To rectify this, money from the settlements should be used to help these deeply affected communities.
One year ago, because of my experience as a sociologist who studies the racial aspects of substance use, I was approached by a prominent Manhattan law firm to be an expert witness in a trial that would potentially provide some answers on the exact scope and nature of the pharmaceutical industry’s influence on the opioid epidemic. The firm was representing a multibillion-dollar drug manufacturer that was being sued by the city of Baltimore for its role in the city’s staggering opioid crisis.
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During the past seven years in Baltimore, illicit use of drugs, namely opioids, has claimed more than 6,000 lives, with older Black men dying at the highest rates, via overdoses. This is the highest per capita figure for any large American city. The law firm was looking to argue, in part, that the epidemic in the predominantly Black city wasn’t connected to the pharmaceutical industry’s actions but rather to intricate, deep-seated issues such as limited economic opportunity and lack of health care access—outgrowths of systemic racism forged by the government and society writ large. In short, their argument was that the pharmaceutical industy was simply a bystander as the opioid crisis, stimulated by everyday people and their social and political systems, unfurled.
I saw the proposed defense as dubious at best. Systemic issues have no doubt played a pronounced role in the U.S.’s opioid epidemic. But if you connect certain dots, you can see how opioid makers may have quietly seized upon these cracks in the system. Despite this, the epidemic’s effect on Black communities has been little more than a footnote in the national opioid settlement initiative, which has seen pharmaceutical titans cough up gargantuan amounts of money in settlements to state and local governments—money that should, in theory, be invested back into the most intimately affected communities.
I ended up parting ways with the law firm several months before the case was set to go to court and without accepting any fees. Unsurprisingly, its client settled with the city of Baltimore, but—like most other opioid makers on trial—had denied any wrongdoing. The client likely backed out early to avoid a lengthy trial, as well as to prevent the public scrutiny that would assuredly come from big pharma’s purported actions—and inactions—in the low-income, minoritized city being shown at trial.
In analyzing some of the national settlements, it’s evident that the funds often aren’t specifically earmarked for some of the hardest hit communities and groups, namely Black communities. Sometimes, these populations don’t even have a proportionate seat at the table to discuss where and how the funds should be used.
Take for example Ohio, which is expected to receive up to $2 billion in settlement funds. Going back to 2017, Black men in Ohio have had the highest rate of drug overdose deaths of any demographic. Ohio officials established the OneOhio Recovery Foundation, a nonprofit composed of Ohian volunteers, to guide the disbursement of the settlement funds. According to a report from a local NPR affiliate in September 2024, only 2 of the board’s 29 members were Black.
For much of the early 2000s, as the opioid epidemic grew, opioid marketing was overwhelmingly targeted to white, upper-middle class people, as well as rural white working-class communities. During this period, prescription opioid use and misuse were substantially higher in white populations compared with Black ones. By the mid-2010s, as consumer sales began to stagnate due to a federal crackdown, big pharma’s marketing practices dramatically shifted, becoming most common in racially mixed counties.
Within several years, the gaps in prescription misuse rates between Black and white people had all but closed. This occurred even though, paradoxically, clinicians have historically been more likely to downplay and neglect Black patients’ pain and deny them opioid prescriptions, on a basis of unwarranted, racialized fears of the patient misusing or reselling them. When people can’t access these medications—either because of a lack of insurance or a prescriber’s resistance—they frequently turn to black-market painkillers and also heroin and fentanyl, cheaper fixes that are more potent and more likely to induce an overdose. Nearly 80 percent of heroin users first start with prescription opioids. On top of this, research consistently shows that opioid use treatments, such as buprenorphine, are less available to Black people than to white people as a result of costs and a lack of access to clinicians licensed to provide treatment.
The government’s failure to prevent big pharma’s racial subversions mirrors past failures. During the 1970s, as the feds cracked down on the marketing and sale of tobacco in white communities, industry giants such as the R.J. Reynolds Tobacco Company (maker of Camel and Newport) began more aggressively pushing their products, namely menthol cigarettes, to Black consumers. Today Black people have disproportionately high rates of smoking relative to white populations and higher rates of smoking-related cancers. A multibillion-dollar settlement was achieved in the 1990s to address the tobacco industry’s years of predatory advertising, but a recent report indicates that only a fraction of the funds have been used for prevention or cessation efforts.
Of the roughly $50 billion currently earmarked from the nationwide opioid settlements in the past five years, states have only received roughly $4 billion, a result of the slow bureaucratic churn of the legal system and state and local governments’ consternation over how to allocate the funds. Unsurprisingly, the effects of the received funds so far appear negligible, given the general steadiness of overdose death rates and findings of persisting racial disparities. Early reports suggest an unevenness in spending is to blame. Funds have been spent on everything from essential resources like lifesaving overdose reversal medications to less essential, more extraneous things like police squad cars and surveillance technology, extensions of the failed, duly racist war on drugs. These initial trends point to more of the same, punctuating the need to better strategize on how we use the opioid settlement funds.
Moving ahead, settlement agreements must robustly account for racial disparities and ensure the government allocates its accrued funds from big pharma lawsuits to more directly target risk factors that have stoked the Black opioid epidemic. Research consistently shows that a lack of access to treatment for mental illness, brought on in no small part by recurrent exposure to racial social stressors and discrimination, is a primary culprit for opioid misuse in Black communities, making this a vital starting point. Funds should also be devoted to increasing the cultural responsiveness of drug treatment programs, as well as prescription monitoring programs that help prescribers determine if a person is “shopping around” for opioids to misuse. This will improve the likelihood that Black people seeking pain relief can be counseled and supported through socially informed approaches before potentially leaping from prescription opioids to even more dangerous street options.
Finally, there needs to be more settlement funding allocated to better supporting community prevention efforts, with an eye toward addressing the precursors to, and outgrowths of, the Black opioid epidemic—namely neighborhood crime, mass incarceration, commercial disinvestment and community blight. These factors alone increase the likelihood that Black adolescents will begin misusing opioids. The government should use settlement funds to specifically focus on expanding early childhood education programs and workforce development programs, subsidizing new developments in at-risk communities and improving neighborhood environments.
You can’t put a price on the Black lives that the opioid epidemic has claimed and will continue to claim in places like Baltimore, but we can begin to put a price on the damage those deaths have done to countless Black communities. Addressing the previously conspicuous factors that exacerbated such damage, including the role of big pharma, and ensuring the government allocates the funding accrued from their legal settlements fairly and effectively will go a long way towards upending this thoroughly preventable crisis.
This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.
