ST. LOUIS — The calls for help poured in throughout the day: Overdose after overdose at the Parkview Apartments here, a double-winged complex with red brick capping the ends.
Six people died that day this past February, five in this building and one at another apartment half a block away. Two others survived their overdoses, according to police.
Two days later, on Feb. 7, two more people fatally overdosed at this 295-unit tower, which sits at the edge of a medical campus featuring some of the city’s top hospitals.
In a stroke, this single cluster added eight names to the grim ledger of American overdose deaths, an epidemic that is taking more than 100,000 lives a year, or roughly 12 every hour. All eight victims were Black — six men and two women, ranging from age 36 to 66, according to the medical examiner’s office. At least some of the victims thought they had purchased crack cocaine, but the drugs also contained fentanyl, court records indicate.
The cluster, while unusually big for one city block, captures how the decades-long overdose crisis has morphed and metastasized once again. Fentanyl and other wildly potent synthetic opioids, often passed off as heroin, are increasingly tainting other categories of drugs like stimulants. Overdoses are claiming the lives of Black people, as well as American Indian and Alaska Native people, at rates never seen before. The changes have health officials scrambling to keep up and suggest that policy makers will have to shift strategies if they hope to save lives.
Last week, the Centers for Disease Control and Prevention, noting historic increases in overdose deaths broadly, reported an “alarming” increase in disparities: the overdose death rate among Black people rose 44% in the first year of the pandemic alone, compared to 22% among white people. And while in 2010, the overdose death rate among Black people was half that of white people, in 2020, the former surpassed the latter, according to a study published in March.
There are few better places to examine the growing toll on Black people than Missouri — which has one of the biggest gulfs in overdose rates between Black and white residents. Here in the state’s overdose epicenter, opioid-related deaths among Black St. Louisans have surged 500% since 2015, more than double the jump among white St. Louisans, according to local researchers.
When Devin Banks, a psychologist at the University of Missouri-St. Louis, tells people that more city residents died in 2020 from overdoses than Covid-19, “they look at me like I have two heads,” she said. There’s a disconnect between the scale of the problem and the accompanying awareness, in part because of whom overdose threatens and how we think of people who use drugs.
“People are running around wearing masks, as they should be — that should have been the public health response” to Covid, said Banks, who runs UMSL’s Racial Equity in Addiction across the Lifespan Lab. “But what should be the public health response to overdose? Like everyone should be running around with Narcan in their cars. There should be much more urgency.”
The reasons for the spike in overdose deaths among Black people, particularly Black men, are both deeply rooted and more recent, according to doctors, researchers, and community advocates. The historic lack of investment in predominantly Black neighborhoods — in infrastructure, economic opportunities, and health care — and the higher rates of incarceration and homelessness that leave people more vulnerable to overdose are now colliding with an increasingly dangerous drug supply. Black people have less access to addiction treatment and overdose prevention tools, and the resources that the country has deployed to fighting addiction have not been effectively targeted to reach Black Americans. On top of that came a pandemic that disrupted services, isolated people, and — while it fueled overdoses across demographics — took a particularly devastating toll on people of color who use drugs.
To experts, the most recent overdose numbers are just another manifestation of the way that systemic racism shapes health outcomes. Such data also challenge the common narrative of who the overdose crisis is harming most — and if responses are geared in the right ways.
“Far from a ‘White problem,’ overdose prevention is now a key racial justice issue,” UCLA addiction researchers Joseph Friedman and Helena Hansen wrote this year in the American Journal of Public Health.
The victims in the overdoses at the apartment building included Elmer Telfair, 45, a guitar player and music lover. “He was trying to get it right, but he was just struggling,” said Telfair’s cousin, Devonte McMiller, who is in recovery from heroin use and is involved with an effort to reduce overdose deaths among Black St. Louisans.
They also included Mark Woods, 61, who enjoyed watching soap operas. “Any time you needed help with cleaning or moving or doing any random task, he would be there,” said his nephew, Matthew Thurman. “And he wasn’t expecting anything back from you.”
The highest overdose rates in the St. Louis area are largely centered in predominantly Black neighborhoods in pockets of the north side of the city and county, and a closer look helps explain why overdose deaths among Black people have been rising.
It’s here, where vacant, overgrown lots and boarded-up structures are interspersed with red brick homes, that many of the social forces that contribute to overdose risk are concentrated, a risk that’s only intensified as the drug supply has grown deadlier. “The forgotten ZIP codes,” as Sandra Mayen of The T, which provides harm-reduction services aimed at reaching Black people, called them.
Going back to a 2014 report, local researchers found that many predominantly Black neighborhoods are also those with high poverty rates and poor health outcomes, with the region’s segregation contributing to an 18-year gap in life expectancy between ZIP codes only miles apart.
In this treatment desert, people might have to rely on multiple buses to get to a clinic — and that is if they have insurance or can pay for care. Those with unaddressed trauma or mental health issues might turn to drugs to self-medicate. Without stable housing, finding and staying on treatment becomes more of a challenge. People who are homeless also face higher overdose dangers, studies show. In St. Louis, Black people are almost four times more likely than white people to be homeless. Nationally, it’s closer to five times.
“In moments of social and economic vulnerability, it’s much harder to get the help you need,” said Magdalena Cerdá, the director of New York University’s Center for Opioid Epidemiology and Policy.
Local providers say it can feel like they’re chipping away at a massive wall as they try to make a dent in drug-related deaths. When they do outreach about overdose prevention in these neighborhoods, they find that people have other issues besides drug use that feel more pressing. They need help controlling their blood pressure, or getting dental care, or treating their depression or anxiety, or finding a place to sleep.
“It’s decades of trauma in the Black community that a small few of us are trying to undo,” said Kanika Cunningham, a family medicine physician in St. Louis.
Certain policies in Missouri have constrained efforts to combat the harms of drug use. State law limits how syringes and fentanyl test strips can be distributed and used (some community groups still provide the resources). And it was only in 2020, after voters approved a ballot initiative, that the state started expanding Medicaid under the Affordable Care Act, a policy that in other states has led to major growth in addiction treatment, including among Black individuals.
Incarceration plays a significant role. While white and Black people report roughly the same rates of illicit drug use, Black people are far more likely to be incarcerated on drug charges. When people leave prison or jail — few of which provide comprehensive addiction care — they are particularly vulnerable to overdose. They might lack housing and health care, and they don’t know how the drug supply has changed. Their tolerance to drugs has also dropped.
“All these things converge,” said UCLA’s Hansen, a psychiatrist and anthropologist. “It’s not a mystery that you’d be at very high risk of overdose. The presence of fentanyl and other synthetic opioids in the drug supply only accelerates that.”
Access to treatment has also been shaped by race. Black people with opioid addiction have historically been directed to programs that offer methadone, an effective but tightly regulated medication. It typically requires daily trips to a clinic to get a dose, which is a major barrier. Separately, researchers have found that even if Black people see a doctor, they are less likely to be prescribed buprenorphine — another opioid addiction medication that can be taken at home — than white people.
Here in St. Louis, Cunningham has incorporated addiction medicine into her practice, something she stresses that other primary care providers need to do. She can stabilize a patient who misuses opioids on buprenorphine, and then take care of their blood pressure or diabetes.
Cunningham grew up in north St. Louis County, and remembers being told to “watch out for dope houses” when she would visit family on the city’s north side. She developed her own bias against people who use drugs.
Now, Cunningham advocates for challenging such notions as a way to keep people safe. Even if her patients aren’t ready to stop using, she’ll work with them to address other concerns, like curing their hepatitis C. She wants her patients to know she cares about them, so her practice distributes packages not just with naloxone and fentanyl test strips but with soap and deodorant and, hopefully soon, pads and tampons. One of her patients used stimulants and came to her every week so she could treat his skin wounds. When he was eventually ready to stop using, she helped him with that, too, she said.
“I want to undo that stigma, undo the harms to our community, and save lives in the process,” Cunningham said.
When the February overdoses made news, people asked Cunningham if she was shocked. Not at all. She was used to hearing how one bad batch of drugs might kill three people on a block.
The overdoses at the Parkview Apartments fit with another trend experts are documenting: Deaths involving both stimulants and opioids have risen in recent years at faster rates among Black people than white people, particularly in eastern states, NYU’s Cerdá and colleagues have found. Some people intentionally use both types of drugs, but some do not realize their cocaine or meth could be contaminated with fentanyl. If people primarily use stimulants, they might not think to have naloxone on hand.
The St. Louis region has experienced a similar increase in combined opioid-stimulant overdoses among Black men in particular, according to Rachel Winograd of UMSL, who monitors state overdose data.
Within days of the initial Parkview overdoses, authorities charged an apartment resident named Chuny Ann Reed with distributing crack cocaine and fentanyl. Reed told investigators she didn’t know the cocaine had fentanyl in it, according to an affidavit. She said she bought drugs outside the apartment and resold it to residents to support her own addiction.
Last week, Reed died, several days after falling ill while in detention awaiting trial, according to court records and Reed’s attorney. The attorney did not yet know the cause of death.
Jamal Preuitt, 39, has been in recovery for almost a year, after surviving nearly two decades of heroin and fentanyl use, two years of homelessness, and three overdoses, he said. Preuitt has gotten treatment not at a typical health center, but at a clinic recently established in a church in north St. Louis, not far from where he was born and raised. The clinic is an example of how local providers are trying to reach more Black people, and of the type of dedicated efforts that experts say are needed to stem overdose trends.
“You ain’t gotta catch the bus to get here, you ain’t gotta be traveling miles,” Preuitt said.
Bryan Moore, the pastor at Jubilee Community Church, had watched as overdoses in the area progressively increased over the past decade. The church provides food to people in need, so if people needed help for their substance use, why wouldn’t the church provide that as well, he wondered.
The idea behind putting clinics in Black churches, both here and in other cities that have piloted such programs, is to offer care at institutions with community trust. People who use drugs are often treated poorly at medical centers, which is compounded by the long-running mistreatment of Black patients generally.
“They will come to a church, they won’t go to a clinic,” Moore said. “It’s as simple as that.”
The clinic, run by Assisted Recovery Centers of America, provides medications for opioid addiction, as well as help finding housing and employment, as well as with other health issues. ARCA has another clinic downtown, but few people from north St. Louis had come over the years, whether because of a lack of transit, a lack of awareness, or perhaps uncertainty about the care they would receive, said Percy Menzies, ARCA’s president.
During the pandemic, ARCA stationed mobile treatment units in church parking lots, in cooperation with Black pastors. It opened the site inside Jubilee last fall. Federal funds routed through the state help pay for care.
“We knew the need was real, and the need was sustained,” Menzies said.
This is not the first time that overdose mortality nationwide has been higher among Black people than white people; the last year was 1999, following eras of heroin and crack use concentrated in Black neighborhoods. But back then, the country responded with prosecution, not public health. It was only in the 2000s, as the overprescribing of painkillers fueled deaths among white people, that the country’s nascent shift to emphasize treating addiction started taking hold. The popular image of someone whose life had been upended by drugs became a white person in Appalachia or the Rust Belt, or perhaps a white teen in the suburbs.
But experts and advocates stress that the country needs to recognize the demographic shift and adapt its response. The perception of who a crisis affects shapes what interventions look like, which community leaders are engaged, and where resources go.
“When it actually hits the front door of white people, then it’s a problem, it’s an epidemic,” said Keith Lofton, who is in recovery and is now a peer support specialist. “But as long as it’s continuously going on in our community, and it doesn’t affect them, there’s nothing to say about it.”
The country has devoted billions to fighting addiction in recent years, but one problem, researchers say, is that the response has broadly not considered how to distribute resources in equitable ways. Too often, programs aren’t tailored for specific populations or don’t engage community groups that are already providing services in the neighborhoods that need to be reached. It could be one explanation for why, prior to the pandemic, the overdose death rate among white people had flattened and even declined while it kept climbing for Black, Indigenous, and Latino people.
It’s an issue that programs in Missouri have run into. One initiative, known as “medication first,” streamlined the process for getting buprenorphine. But researchers found that by some metrics, it was more successful among white people than Black people.
“We speculate that this was a first-come, first-serve situation, and information about low-barrier buprenorphine traveled fast though local harm reduction and overdose prevention circles, which are predominantly white in the St. Louis area,” researchers concluded, citing few providers in predominantly Black neighborhoods and “the lack of culturally responsive treatment modalities and cultural humility among treatment providers.”
“Through our lack of centering racial equity, we contributed to the inequitable access” to treatment, they found.
In a paper this year, a group of Black and Latino providers noted that the devastation of opioids in predominantly white communities had changed the conversation around drugs. “We have observed that harm reduction and addiction medicine have gained significant financial and political support as a result of this recent attention to opioid use,” they wrote, but added “that few of the supported efforts are led by Black or Brown practitioners.”
That needs to change if initiatives to reduce overdoses are going to work, said Ayana Jordan, an author of the paper and an addiction psychiatrist at NYU.
“These services have to be led by the people who are most affected,” Jordan said. “If that doesn’t happen, we will continue to see worsening disparities.”
Missouri officials are trying to be more conscientious. The state has started providing grants to community groups in north St. Louis to link people to treatment, reaching beyond its usual partners.
A group of academics, clinicians, and advocates has also formed the CENTER Initiative to specifically take on deaths among Black St. Louisans. A major component is to provide naloxone to Black individuals, who, researchers in a number of cities have found, have less access to the medication. There aren’t many grocery stores in these targeted neighborhoods, so the campaign is enlisting corner stores to have it on hand. They’re also trying to get it directly to people who use drugs, who are among the most likely to be around someone who overdoses. In addition, many Black people don’t feel safe calling 911.
The initiative’s leaders include UMSL’s Banks and Cunningham, the family medicine physician, and they’re relying on grassroots groups like The T that already have connections with the people they’re trying to reach. They’re planning discussions with people who use drugs to learn how to best serve them, and have built a community advisory board that includes faith leaders, health workers, and people in recovery, including McMiller and Lofton.
One advantage of Black-led approaches, Banks said, “is the potential for trust.” She pointed to the importance in particular of having people in recovery involved. “Especially that peer support — what they offer is hope.”
This story is part of a series on addiction in 2022, supported by a grant from the National Institute of Health Care Management. Previous articles covered risks from a veterinary tranquilizer spreading in the drug supply, and the Americans with Disabilities Act’s protection of people with addiction histories.