The first victims of the country’s opioid epidemic were predominantly white, living in rural communities devastated by prescription painkiller addiction. With doctors less likely to prescribe adequate pain medication to Black patients, racism protected Black Americans from the first wave of opioid deaths.

Now, the face of the epidemic has changed. New federal data points to a sharp shift in the mortality trend, one that’s catastrophic for Black communities.

The number of fatal drug overdoses increased 44% among Black people between 2019 and 2020, the largest spike of any race, according to a new analysis by the U.S. Centers for Disease Control and Prevention. The racial disparities have been widening: For older Black men, the overdose death rate is nearly seven times that of older white men.

In total, a record-breaking 92,000 lives were lost to drug overdoses in 2020, the vast majority of them related to opioids.

Fentanyl, an extremely potent synthetic opioid, is changing who falls victim to the epidemic, said Mbabazi Kariisa, lead author of the latest CDC report. The drug is often mixed into other substances, like cocaine and heroin, she said, and most people are unaware their drugs are laced with it. Fentanyl has sent overdose death rates skyrocketing, particularly among Black Americans.

There are other drivers of the crisis for Black people, including mental health stigma and the legacy of the war on drugs. Exposure to racism also can increase the likelihood of substance abuse.

Reducing mental health stigma will decrease rates of substance use disorders and overdoses, experts say. But more immediately, they point to gaps in community education and disparities in the effectiveness of treatment and access to medications that have proven to slow the crisis in white communities.

“A lot of Black people don’t even realize they’re a part of the overdose crisis,” said Dr. Ayana Jordan, an associate professor of psychiatry at NYU Langone Health who studies addiction disparities. “If you are using substances that are illicit, that are not regulated, there is a very high likelihood that it’s going to contain fentanyl and that puts you at risk of overdose.”

Black Communities Grieving

Addiction’s wrath has rippled through Desilynn Smith’s family: taking her husband and most recently claiming the life of her aunt. In the past year, the Milwaukee resident has known 15 people who have died of confirmed overdoses.

“It’s sickening to me and it’s heartbreaking,” Smith said. “Substance addiction wasn’t actually the problem, it was their solution to dealing with the problem.”

Just months after her husband died of a fentanyl overdose in early 2021, Smith confessed her guilt to news reporters covering the overdose trend. For the first time, she was confronting the pain of admitting her first love had been struggling with addiction.

“No one knows what he’s dealing with at home or within himself but me, and I didn’t know what to do with it,” she said. They were once teenage sweethearts. He was her protector, she said. “I could’ve done more.”

Smith, who lost her husband in 2021, has immersed herself in behavioral health work and is opening a trauma and substance abuse clinic in her community. She fields complaints from residents about the health workers who label them “opioid addicted,” toss them medication and tell them to come back in two weeks. The patients Smith talks to don’t understand the terms doctors use to discuss their addiction. “Recovery,” a clinical word for “getting better,” she said, means little to people who only know that they are struggling and need to feel OK again.

Understanding the language communities use to describe their substance use is essential to addressing the crisis, said Danelle Stevens-Watkins, a professor at the University of Kentucky who has studied substance use for nearly two decades, and that language will vary from the deep South to the Midwest. The factors driving overdoses among Black Americans also vary by age, she said.

“The glorification of opioid misuse in rap culture, in urban culture, in music culture, and even the deaths of famous rappers and artists from opioids, that is one influential factor among younger folks,” she said. And for older generations who are dealing with more chronic illness and pain, mixing medications can lead to unintended overdoses. That is particularly true for Black Americans, who are disproportionately likely to face many different diagnoses over the course of their lives.

“They might not be aware that mixing these drugs, they might lay down and not wake up,” said Stevens-Watkins.

Unequal Treatment

Consequential disparities also persist in access to opioid treatment that has been proven effective. Often Black patients aren’t assessed for substance use disorders, and when they are, they are less likely to receive buprenorphine prescriptions than white people, said Jordan, the NYU professor. It’s a first-line, life-saving treatment for opioid use disorder.

“It goes back to whose lives are valued in this country,” she said. “We need to take away blame from Black people with opioid use disorders and other substance use disorders and really put the magnifying glass on how treatment is provided.”

And because many of the overdose intervention programs are police-led, they may not be reaching their full potential in Black neighborhoods. In the midst of an emergency overdose, people are afraid to call 911 out of fear of being arrested, said Khary Rigg, an associate professor in the Department of Mental Health Law and Policy at the University of South Florida.

It’s tough to pivot from leaning on mass incarceration to wanting to be seen as a source of help in a drug crisis.

“For so many years, these have been used to throw people in jail,” Rigg said. “I don’t think these interventions, when they’re implemented in these communities, keep the legacy of the war on drugs in mind.”

In Rhode Island, Dennis Bailer runs an overdose prevention program. A former crack cocaine smoker himself, he’s seeing people who are using traditional drugs, like heroin, die at much higher rates due to them being laced with fentanyl. Most users he knows are not aware of its lethality, he said.

“Substance use disorder has no boundaries in terms of who it affects,” he said. Yet, the disparities in treatment persist. White users are victims, said Bailer, but Black folks are criminals. “We feel like the system is just stacked against us.”

He often hears the Black and brown people he works with on the street say that they don’t feel included in the efforts to save lives. Compared to white communities, they don’t have the same access to Narcan, a nasal spray that can reverse an overdose in an emergency, and fentanyl test strips, a low-cost method to test drugs for the synthetic opioid.

“Racism exists. Second-class citizenship exists,” said Bailer. “It’s not a myth. It’s not something from our distant past. It’s there. It’s present. It’s seen by so many of us.”

Margo Snipe is a health reporter at Worldacad. Twitter @margoasnipe