chapter 1

Pharmakon of Racial Poisons

and Cures
(as told by Helena Hansen, psychiatrist-
anthropologist)

“Why did you stop working as a journalist?” I asked. Charlie* pulled

his black T-shirt over his tattooed shoulder and ran his fingers through
his buzz cut. “I got fired.” His eyes darkened. “I don’t blame them.
Toward the end I got pretty outrageous. I showed up for work totally
high, so high that one day I had a needle and syringe hanging from my
neck with blood running from it. I didn’t even realize.”
Charlie was part of a crop of educated white patients who were
beginning to appear at this large New York City hospital. It was the
only public hospital in the region that, at that time, offered treatment
with buprenorphine, commercially known as Suboxone. Ordinarily, the
hospital’s clientele was Medicaid insured or uninsured, Latin American,
African American, or recently migrated from China. The white patients
we saw were undocumented immigrants from Poland or Russia, many
of them day laborers living in Coney Island. If we saw American-born,
white patients, they had been homeless for long periods of time before
being sent to us for treatment by a shelter social worker or a drug court.
But the patients in the new Suboxone clinic were different. The clinic
was on the primary care unit, nestled in between diabetes and asthma

* All names of patients and opioid users in this book are pseudonyms, and key ele-
ments of their biographies are hybridized with those of other patients and opioid users in
order to protect their identities, which was a condition of their consent to participation in
my research. The same is true for Drs. Pine and Abrams.

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 4   |   Technologies of Whiteness

specialists, and was open only one day per week. It was staffed by a
vanguard crew of primary care doctors who had gotten certified to pre-
scribe Suboxone because they were committed to bringing new tech-
nologies to indigent patients.
I first saw Charlie in 2009, but the clinic had been founded in 2005,
three years after the US Food and Drug Administration (FDA) approved
buprenorphine for treatment of opioid dependence, by Dr. Abrams, an
internist who had made his name promoting harm reduction and HIV
treatment for heroin-addicted people. Abrams had recruited Dr. Pine, a
buzz-cut, muscular physician, to lead the Suboxone clinic. He looked
like a Marine but spent his free time volunteering in homeless shelters.
Pine gave his personal cell phone number to all patients who were start-
ing Suboxone and encouraged them to call with questions about how to
dose themselves in the first twenty-four hours of treatment. He wel-
comed everyone but did not expect to see so many patients come in
from the suburbs. These new patients commuted to our clinic because
they would not, or could not, pay the $1,000 fee charged by private
doctors near their homes for an initial Suboxone prescription.
None of the staff had predicted that their Suboxone clinic, the first of
its kind in a public New York City hospital, would draw patients from
affluent suburbs in Long Island, Staten Island, and New Jersey. Although
many of these new patients were on Medicaid, and some were unin-
sured, a good number had attended college and had worked as profes-
sionals before their opioid use got in the way. Charlie was an example.
His father paid the rent on his studio apartment in the fashionable East
Village neighborhood of Manhattan, but he was on food stamps and on
Medicaid, having exhausted his unemployment benefits.
Charlie’s sojourn to our public clinic was one sign of a massive shift
in American imagination surrounding addiction.† The ascendant “brain
disease” model of addiction afforded opioid- and heroin-dependent
middle-class white Americans an escape valve from the racialized moral
blame that has historically been attached to narcotics in the US. The
language used to describe addiction changed in accord with this shift to
locating problem drug use in biological causes—in neuroreceptor dys-
regulation or genetics—and away from locating it in the character flaws

† Throughout the book we use the colloquial term addiction and the more neutral
term problem substance use in order to distinguish everyday understandings from the
clinically diagnostic terms substance use disorder and opioid use disorder in order to
highlight how biomedical practitioners and pharmaceutical manufacturers use clinical
language to shift the definition of problem drug use toward that of a biological disease.

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 Pharmakon of Racial Poisons and Cures   |   5

of the individual, or in social influences on the person. Increasingly,

clinical journals and later the popular press replaced the terms addic-
tion and substance abuse with the diagnostic terms substance use disor-
der and more specifically opioid use disorder.
The logic of the brain disease model not only opened the door to bio-
medical treatment for addiction but also made the idea of technological
fixes for the addictiveness of new formulations of opioids plausible; opi-
oid manufacturers tapped into its ethos in their claims of safety and the
aggressive marketing of technologically enhanced opioid pain relievers
to insured, largely white Americans. Then, in response to the overdose
crisis, the brain disease model led to pharmaceuticals as the primary
response to problem drug use such as opioid use disorder. It led to federal
promotion of buprenorphine maintenance as a rational, modern, sci-
ence-based approach to addiction under the rubric of “medication-
assisted treatment,” or MAT, increasingly referred to as “medication for
opioid use disorder,” or MOUD. Buprenorphine’s advocates hailed it
as a neuroscience-based, radical new policy innovation. But in fact,
methadone maintenance for opioid addiction had been available,
primarily for poorer Black and Brown people, since the late 1960s. What
was new was the effort to, quite literally, whitewash addiction and
addiction treatment—to replace the stigma and aggressive policing of
methadone with the cleaner, medicalized empathy of buprenorphine.
Yet even this effort was not new. It drew on a century-old system of nar-
cotic segregation in the US, in which some drugs become illegal through
association with nonwhite users, and other drugs are legal and are
deemed “medicines” reserved for white and middle-class consumers: in
short, a system in which the Whiteness‡ of certain drugs medicalizes
them.
In this book, we examine this 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 white imagery to
hide or cover the inner workings of segregation in drug policies and
health care industries. It also refers to the need to bring Whiteness out
of the silence and shadows of drug policy and health care so that it can
be seen—so that its harms to white people and people of color can be
collectively addressed.

‡ Throughout this book, we capitalize Whiteness in order to bring attention to it as a

system that undergirds the phenomena we describe, as opposed to racial identity as sig-
naled by white, which we do not capitalize.

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 6   |   Technologies of Whiteness

The buprenorphine clinic of this New York City hospital was a theater
in which the contradictions and ironies of this system came into view.
Like Charlie, the buprenorphine clinic patients were not only more likely
than traditional public addiction clinic patients to be white but also more
likely to be young and physically healthy. Many had never before needed
health care and were not used to the routines of a large public hospital.
Jennie, a thin blonde woman who arrived at monthly appointments in
form-fitting gym clothes, commuted almost two hours from her house at
the far end of Long Island. The staff chuckled when they saw her name
on the appointment list. “Oh, it’s Jennie. We can take the other patients
first.” She never arrived at her appointed time, but when she did arrive,
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’s
nowhere to park. Could you just bring down my script?” None of the
staff ever brought down her prescription. She always ended up parking
at a meter on the crowded city streets nestled between high-rise build-
ings, but not before calling from downstairs. The clinic manager had her
own theory as to why. “She thinks we are dealers. In Long Island, the
dealer hand-delivers the goods to you in a strip mall lot.”
Jennie took her prescribed Suboxone tablets in her own way. Mon-
day through Thursday, before leaving for her office job, she took them
at breakfast, as her doctor instructed. But on Friday she would some-
times skip her dose so that she could “feel something” when she cele-
brated Saturday and Sunday with OxyContin from a dealer. She was
honest with her doctor about it. Her doctor kept prescribing Suboxone,
reasoning that at least Monday through Thursday, Suboxone kept her
safe from overdose and arrest. This fit the rationale behind Suboxone
treatment: reduce the harms of illegal opioid use by prescribing safer,
medical opioids to prevent opioid withdrawal symptoms and reduce the
patient’s use of dangerous street drugs.
Even those most committed to the logic of Suboxone treatment can
have a hard time freeing themselves entirely from older conceptions of
addiction. Jennie’s doctor, for example, was still worried about her
patients’ decision-making. She carefully screened all of her patients for
signs that they were getting pleasure from Suboxone, and she lowered the
dose if they were. She reminded patients to take Suboxone every day at
the same time, “like a vitamin,” and lectured them on the difference
between a medication—designed to prevent withdrawal symptoms—and
a drug that was used for pleasure. Perhaps she worried about the most
common critique of medications for opioid use disorder—that maintain-

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 Pharmakon of Racial Poisons and Cures   |   7

ing patients on Suboxone, itself an opioid, was just substituting one addic-
tion for another. Her worry revealed that, while more medicalized than
the prior century of American responses to drug epidemics, buprenor-
phine and other medications for opioid use disorder had not completely
displaced older ideas that narcotics users needed to be disciplined.
The Suboxone clinic was only two floors below the methadone clinic,
in the same hospital, but it rarely got referrals from, or made referrals
to, the methadone clinic. The methadone clinic ran as it had run for
decades: serving primarily African American and Latinx people from
the South Bronx and Lower East Side of Manhattan, along with a hand-
ful of middle-aged, homeless white patients. Patients lined up in one of
two shifts—at 7 a.m. or at 3 p.m.—in front of a medication window
where a nurse watched them drink methadone from a cup and checked
their mouths to ensure that they were not “cheeking” the medication
for resale on the streets. After the line thinned and the medication win-
dow closed, patients gathered in group therapy rooms. The methadone
clinic ethos was communal; it lacked the trappings of patient privacy.
I knew that private-office buprenorphine represented an important
new development as an alternative to methadone clinics. When I was in
medical school, my professors had run an early clinical trial of buprenor-
phine for opioid addiction; this was in the late 1990s, before it was
approved by the FDA for addiction treatment and received the com-
mercial name of Suboxone. These professors were excited by buprenor-
phine’s promise to “change the culture of medicine”: to have addiction
finally recognized as a chronic, physiological disease, similar to diabe-
tes, asthma, or hypertension and treated in the same way—with long-
term medications—and in the same places, primary care clinics. They
were eager to find alternatives to methadone. Methadone clinics were
so stigmatized that they were often located a bus or train ride away
from their parent hospital, in run-down neighborhoods whose residents
were not organized enough to protest them. Methadone clinics were
regulated by the Drug Enforcement Administration (DEA), required
daily observed dosing, and had such restrictive hours that at times
patients had to choose between methadone and a job. Affluent white
patients usually refused to be seen at a methadone clinic, and most poor,
rural, white patients lived hundreds of miles from one.
• • •

The golf resort’s largest lecture hall was filled to capacity with addiction
specialists attending the annual meeting of the College on Problems of

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 8   |   Technologies of Whiteness

Drug Dependence (CPDD). The much-anticipated panel addressed the

question of how to reduce the risk of overdose from prescription opio-
ids. The second speaker was from Purdue Pharmaceuticals, manufac-
turer of OxyContin. He presented protocols for physicians to screen
patients for risk of prescription opioid misuse, and graphs showing that
use of the protocols led physicians to select patients for opioid pain
relief who had lower rates of overdose.
The next speaker was slated to speak about the effectiveness of
naloxone opioid reversal kits in reducing overdose. But he went off
script. Turning to the speaker from Purdue, he leaned into the micro-
phone and said in a sharp tone not often heard at this otherwise dry,
scientific meeting: “Before I speak, I want to point out what you are
doing for Purdue. You are putting blame for overdose on the patients,
and on prescribing physicians. Overdose is not due to inadequate patient
screening. It’s due to the false claims and marketing of your company.”
After a moment of silence, audience members stood up one by one to
clap. After a few minutes, most of the room stood in a standing ovation.
This was an awkward moment in the history of the CPDD, the oldest
and largest organization focused on the science of substance use disor-
ders in the US. Founded in 1929 by the National Academy of Sciences,
from the beginning it faced questions about responsible clinical use of
narcotics and narcotic drug development in an era of federal prohibi-
tionist policies that limited physicians’ use of narcotics. An exclusive
organization to which new members had to be invited, the CPDD show-
cased pharmacological science and clinical trials; its members were
leading researchers and authorities on state-of-the-art treatment. After
World War II, its members thrived on federal funding for laboratory
science in the Cold War race for modernity. CPDD, originally called the
Committee on Drug Addiction, had ties to the pharmaceutical industry.
It secured corporate funding for early animal and human testing of syn-
thetic opioids and fed data on promising compounds back to manufac-
turers,1 and its corporate sponsorship dated back to the 1950s.2 By the
time of my attendance at their annual conference, the CPDD had phar-
maceutical executives on its board and hosted “Friends of NIDA”
(National Institute on Drug Abuse), a group of industry donors to
addictions research.
The panelist I had just witnessed pointed out one way that research
could be reframed in the interest of pharmaceutical manufacturers. The
connection that the panelist did not make, but that I came to make in
studying how opioids became white, was that ideas about who is “at

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 Pharmakon of Racial Poisons and Cures   |   9

risk” for addiction and overdose from prescribed opioids were the key
not only to pharmaceutical company strategy but also to the demo-
graphics of overdose. While the Purdue Pharmaceuticals researcher at
this conference encouraged physicians to begin screening their patients
for risk of addiction, his company had in fact employed many screens in
their marketing since OxyContin’s 1996 FDA approval for pain. These
screens involved the geographic targeting of white neighborhoods and
coded drug representative language about prescribing to “trustworthy”
and “legitimate” patients among American physicians who had been
shown to attribute lower addiction risk to white patients and to attribute
higher tolerance for pain, and thus less need of pain relief, to Black
patients.3 The success of blockbuster drugs such as OxyContin and
analogous new opioids such as Opana and Roxicodone, followed by
the success of blockbuster formulations of buprenorphine such as Sub-
oxone for treatment of opioid dependence, hinged on appealing to long-
standing race-based popular, professional, and political conflations of
biology with morality, as well as to race-based distinctions between the
need for medical treatment versus punishment.
When I started observing the buprenorphine clinic of my hospital, I
did not know that I was seeing a pharmaceutical response to what the
national press called the “new face of addiction.” I did not know that the
opioid buprenorphine, sold as Suboxone, was especially designed and
marketed as a white treatment for dependence on another white drug,
OxyContin. OxyContin’s manufacturer finessed traditional federal
restrictions on opioids; its marketing targeted suburban and rural pri-
mary care physicians—those with a white patient population—leading
them to prescribe it for an unprecedented range of conditions beyond the
severe postsurgical and cancer pain to which opioids had long been
restricted. The manufacturer promoted new indications for OxyContin
including lower back pain, contributing to a tripling of prescription opi-
oid sales within the first decade after OxyContin’s FDA approval as a
less addictive opioid formulation appropriate for “moderate pain.”4
It turns out that racial patterns of access to opioid pain relievers, and
to pharmaceutical treatments for addiction to them, are not uninten-
tionally caused health disparities. Rather, they are produced by inten-
tional racialization, not only of drug policy, but of the drugs themselves.
I could not have predicted then how interesting OxyContin and Sub-
oxone would become from the standpoint of drug development, drug
policy, and race—that chemically and symbolically forged within the
American cultural politics of narcotics, OxyContin and Suboxone were

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 10   |   Technologies of Whiteness

encoded from their inception with white racial identities, designed to

confer Whiteness on those who took them.
It happened that the Suboxone clinic that I studied opened on the
heels of New York’s heroin chic of the 1990s, involving young affluent
whites, including fashion models such as Kate Moss. Columbian drug
cartels had begun marketing cheap, snortable heroin to the white Amer-
ican middle class; they sent high-purity heroin to local distributors in
major US cities such as New York, knowing that this would lower the
cost of Colombian heroin below that of competing cartels in the Middle
East and Asia, and that the high purity of Colombian heroin would
enable heroin snorting among middle-class users, who saw injection as
highly stigmatized but had long sniffed powder cocaine. This strategy
followed Colombian cartels’ successful marketing of crack cocaine to
poor US Black and Latinx people; the cartels later diversified their mar-
kets by planting poppies in order to produce heroin.5 US authorities had
responded to the cartels’ successful ethnic marketing of crack with
racially disparate sentencing through the 1986 Federal Anti-Drug Abuse
Act, which mandated five-year mandatory-minimum sentencing for
crack possession, with only one-one-hundredth the weight of crack
(seen as a Black drug) compared to powder cocaine (seen as a white
drug) needed to trigger sentencing. It is an example of drug policies
based on racial imagery (reflected in policy makers’ references to inner-
city crack-addicted “superpredators”) that exacerbate racial inequalities
through disparate law enforcement and sentencing, but without naming
race—an example of the institutional “color-blind ideology” described
by Michelle Alexander.6 This disparity foreshadowed later law enforce-
ment distinctions between nonmedical prescription opioids and heroin.
I learned of Suboxone during the late 1990s’ rise of prescription opi-
oid use in the suburbs, when opioids began their ascent to the most
prescribed drug class in the US.7 By 2010, opioids were second only to
marijuana as the most common recreational drug among high school
seniors.8 All this was happening in the midst of a national move toward
stop-and-frisk and sting operations in Black and Latinx city neighbor-
hoods that led drug charges to drive unprecedented incarceration rates,
peaking in 2008, and putting the US prison population well above all
other countries in the world in terms of both percentage of population
and raw numbers.9
White opioid use and pharmaceutical addiction treatment grew in
the midst of an intensified inner-city drug war. To make sense of this
pattern, I observed dozens of drug policy and addiction science meet-

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 Pharmakon of Racial Poisons and Cures   |   11

ings, observed interactions in clinics over four years, and interviewed

over two hundred addiction scientists, treatment advocates, pharma
executives, policy makers, administrators, prescribers, and patients. In
the process, I discovered an unrecognized form of ethnic marketing
that, because it targets white people, works by not marking itself as
racial. The story was invisible by design. Only through sustained par-
ticipant observation and interviews with key participants have I been
able to unravel the threads.
Intrigued by the aspirations of my medical school professors to rede-
fine addiction as a chronic medical illness, I started my study with Sub-
oxone. It is easiest to see its racial identity by comparing it to its pred-
ecessor, methadone, the only other opioid that can legally be used to
treat opioid dependence in the US. The first nationally representative
study to compare buprenorphine patients to methadone patients by
race and class found that in 2005, three years after FDA approval of
office-based buprenorphine, 91 percent of buprenorphine patients were
white, over half had attended college, and over half were employed at
treatment initiation, compared with methadone patients, 53 percent of
whom were white, 29 percent of whom were employed, and 19 percent
of whom had attended college.10 By 2019, another national study found
that among patients with opioid use disorder, whites were still three to
four times as likely as Blacks to receive buprenorphine, and the vast
majority of those receiving buprenorphine (at a cost starting at $300
per month) paid for it with cash or with private insurance rather than
Medicaid or Medicare.11
What we did not know from these trends was how they had occurred:
How had the two pharmaceuticals, methadone and buprenorphine,
been racialized? By what process had they gained their racial identities?
For that story, I went back to 1965. Race riots had burned through
Harlem, Philadelphia, and Watts, Los Angeles. The unemployment rate
for Blacks was twice that of whites.12 The Mafia had years before gained
control of Asian heroin imports and had recruited a sales force from
Black and Latinx inner cities.13 Also in that year, Rockefeller University
diabetes researcher Vincent Dole, who conceptualized heroin addiction
as opiate receptor deficiency, analogous to insulin deficiency in diabe-
tes, published findings from the first clinical trial of methadone mainte-
nance with his coinvestigators Marie Nyswander and Mary Jeanne
Kreek.14 The study’s subjects were African American heroin-injecting
men from Harlem, and its outcomes of decreased criminal activity and
increased employment at six months brought it national attention. By

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 12   |   Technologies of Whiteness

1970, news of methadone as a pharmacological solution to urban her-

oin reached President Nixon, who appointed pioneering psychiatrist
and methadone advocate Jerome Jaffe as the nation’s first drug czar.
Nixon targeted inner-city Black and Latinx people, as well as returning
Vietnam veterans, with methadone, the major weapon in his War on
Drugs.15 To prevent diversion and street sale of methadone, the DEA
regulated methadone clinics, requiring daily observed dosing and regu-
lar urine testing. Because of community resistance, the clinics were
located in marginal neighborhoods in the city, remote from other medi-
cal services.16
What I noticed in reading about the architects of 1970s methadone
policy was their prevailing concern in that period with containing
unruly Black populations. Methadone was a Big Government interven-
tion in the midst of racial unrest, of white flight from “urban crime,” in
the era of the War on Poverty. Beny Primm, a prominent African Amer-
ican physician who founded the first methadone programs in New York
City’s Black neighborhoods of Harlem and Bedford-Stuyvesant Brook-
lyn in the 1970s, told me that methadone was met by suspicion in Black
communities given its connection to crime control: “The Democratic
party had pretty much decided that [Mayor John Lindsay] was going to
be their [presidential] candidate. . . . One of the shortcomings of his
mayoralty reign was that he hadn’t done very well for the addict popu-
lation, neither in Harlem nor Brooklyn nor elsewhere, and it was kind
of taking over the city, and crime was rampant. . . . I had gotten caught
up in the street thinking about methadone, that, as it were, white people
[were] further enslaving Black people who were on drugs, and I was
part of that whole cabal.”
Despite this resistance, early methadone scientists successfully lob-
bied for methadone to become the standard of medical care in largely
Black and Latinx urban neighborhoods. In the late 1960s and early
1970s, they used the language of neuroscience to argue for pharmaceu-
tical treatment of addiction as a biological rather than a social problem.
As Mary Jean Kreek, who coauthored one of the first papers on metha-
done maintenance with Vincent Dole and Marie Nyswander in 1966,
recalled in her Rockefeller University lab during our 2011 interview:
“We therefore set the hypothesis that opiate addiction, and I’ve extended
that to all addictions, are not criminal behaviors, nor are they weak
personalities. They are diseases of the brain with behavioral manifesta-
tions that include drug hunger, drug craving, drug seeking, and drug
self-administration.” The tension between the explicitly racial politics

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 Pharmakon of Racial Poisons and Cures   |   13

around 1970s inner-city heroin and the universal, deracialized language

of neuroscience gave methadone the ambivalent, quasi-medicalized,
and still marginal position that it holds in clinical care today.
Fast forward to October 8, 2002. A new kind of opiate problem had
developed following Purdue Pharma’s aggressive marketing of OxyCon-
tin as a minimally addictive pain reliever. Most of these newly addicted
people were white and many of them middle to upper income. The FDA
had just approved the synthetic opioid buprenorphine for maintenance
treatment of dependence on opioids such as OxyContin in certified doc-
tor’s offices. Like methadone, it blocked opiate receptors in the brains of
addicted patients, but unlike methadone, it could be prescribed monthly
for use at home. This was the first time since the 1920s that generalist
doctors were permitted to use opioids to treat opiate addiction.
The manufacturers of buprenorphine, and the architects of opioid
treatment policy almost thirty years after methadone, working in a period
of health care privatization and of rapid growth in psychotropic pharma-
ceutical markets, had to distinguish buprenorphine, symbolically and spa-
tially, from racially burdened methadone. Buprenorphine, pharmacologi-
cally in the same drug class as methadone, had to be whitened. That is,
manufacturers had to craft the social identity of buprenorphine to contrast
with that of methadone in terms of race and class; to associate buprenor-
phine in the popular and clinical imagination with white, middle-class—
and therefore legitimately ill, treatment-adherent, and noncriminal—
consumers. In this book, we argue that they actively achieved this
Whiteness of buprenorphine with specific social technologies.
• • •

This book examines Whiteness in US society as an ideological system,

rather than a biological trait or as something an individual possesses. It
tracks the way that ideas about Whiteness operate through opioids in
contemporary biotechnologies, consumer markets, and drug policies.
This is a story I have been following for two decades—while training in
addiction medicine; practicing addiction medicine; and observing and
interviewing the scientists, policy makers, and company executives that
disseminate new opioids, as well as the people to whom they are mar-
keted. I tracked these actors as they moved between clinics, laboratories,
policy committees, homes, homeless shelters, social service agencies, and
courtrooms. Over time, I assembled a fieldwork team that did observa-
tions in clinics and pharmacies and scoured the archives for pharmaceu-
tical ads and for legal records of lawsuits against manufacturers. Our

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 14   |   Technologies of Whiteness

team of undergraduate and graduate students of anthropology, public

health, and social work research (Alyssa Rivera, Parth Patel, Caroline
Parker, Sonia Mendoza, and Alexandrea Hatcher) was multiracial and
made up of astute analysts of race.
To write this book, I joined forces with sociologist Jules Netherland
at the Drug Policy Alliance, with whom I have had a decade-long writ-
ing partnership on the Whiteness we saw evolving in opioid policy and
media coverage. Together we looked at Whiteness and opioids from
many angles: as it manifests in community clinics, scientific meetings,
sessions of Congress, and national news. Jules and I then reached out to
David Herzberg, whose work on the history of pharmaceutical White-
ness we had been citing. David was the linchpin of thought-provoking
conferences and journal issues on the history of drug policy, drug mar-
keting, gender, and race that had profoundly shaped our thinking.
The story of Whiteness through opioids has become personal. Many
of my heroes—Black, white, Latinx, and otherwise—have died of over-
dose and of many other drug-related causes along the road to my writ-
ing this book. The deceased include members and relatives of a video
therapy group in the New York City public addiction clinic in which I
volunteered for ten years. Walter, an Afro-Caribbean war veteran who
had put his life on the line for his country many times, told us on video
that he’d twice escaped death after serving in Iraq: once when driving
under the influence led him to roll his car over the side of a bridge, and
once in a drug-induced attempt to hang himself before his dog pulled
him down from a tree. In his second year of sobriety, when Walter had
embraced his will to live and had reunited with his daughters, he was
diagnosed with a form of cancer that was likely caused by his drug use.
Rob was the beloved brother of Ruben, a Puerto Rican cab driver
who became an outsider artist as a result of our clinic’s art therapy
group. Our video group camera crew filmed Ruben reuniting with his
brother Rob after decades of estrangement. One week later, Rob was
beaten to death outside of a bar in drug trade–related retaliation.
The list of video group members and of drug casualties goes on:
Black, white, Chinese, and Mexican American, some educated, more of
them working class, a large number referred to us by the homeless shel-
ter next door to the clinic.
At least one member of our video group was acutely aware of her
own Whiteness and her affluence. Julia, of quick wit and Marilyn Mon-
roe upsweep, had actually worked in Hollywood as a producer before
coming to New York for a mental health break. The granddaughter of

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 Pharmakon of Racial Poisons and Cures   |   15

a food industry mogul, she felt survivor guilt when video group mem-
bers talked of serving time for drug charges and seeing roommates mur-
dered in their homeless shelters. She paid their legal bills and overdue
rent; she brought enormous platters of food to our video shoots as she
nibbled quietly on salad. A short-statured woman standing under four
feet tall, she had grown up among wealthy white people who put a pre-
mium on thinness. She was terrified of becoming fat on top of being
short. For years she struggled with using stimulants to keep thin, even
though they gave her high blood pressure. Ultimately, she convinced a
private psychiatrist on the wealthy Upper East Side of Manhattan to
prescribe her stimulants for an adult ADHD diagnosis.
A month later she was found in the back of a taxicab, slumped over
from a massive stroke. Julia was a casualty of the double-edged “privi-
lege” of access to narcotics in the private, legal, yet treacherous white
pharmaceutical market. At her memorial in the clinic, we screened a
short film that we had made from the rare footage that, without her
noticing, we got of her during shoots where she always worked behind
the camera. There was not a dry eye among the fifty-plus current and
former drug users in the room, who reminded each other that Julia had,
in the end, gotten her wish: to die “young and beautiful.” And I won-
dered what would have happened if her upscale psychiatrist had helped
her to see how much she meant to us, and to see that she did not need a
prescription, or to be thin.
There are other ways that drugs and race are personal for me. I grew
up in a middle-class Black household in the 1970s and 1980s, first in
Oakland, California, and later in Berkeley near the university campus.
Race and drugs hovered beneath the surface of our family dynamics and
of local politics. I saw the vestiges of the hippie movement when some
of my white classmates’ parents smoked marijuana in public. In high
school, the parents of white students encouraged them to try marijuana
and other drugs as a route to self-discovery.
At home with my single mother, my maternal grandparents, and my
younger brother, we knew that only white people could do such things.
My mother was the embodiment of Black middle-class respectability;
she insisted on clean, ironed clothing that fully covered the body. She
spoke with perfect grammar and was nauseated by the smell of mari-
juana and other drugs. She studied child psychology and eventually took
a job in the county’s child protective services, where she saw hundreds
of poor Black and Latinx children sent to foster care when their mothers
tested positive for drugs, against her professional advice. Over and over

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 16   |   Technologies of Whiteness

again she told judges that child attachment theory directed them to give
extended families, if not birth parents, the financial and social support
they needed to keep custody. But instead, the institutional incentives of
the foster care system were to take children away from mothers of color
and to pay foster parents—most often white people living in rural or
suburban white areas—to care for them. Although she was a psycholo-
gist, my mother did not see child removal as the result of parents’ psy-
chological problems. She saw the need for socioeconomic stabilization
of Black and Brown families and neighborhoods that had been deci-
mated by the outsourcing of members to jails and prisons on drug-
related charges. As if that decimation were not enough, my mother
observed, drug and sex traffickers preyed on Black and Latinx foster
children who had no kin to protect them as they aged out of the foster
system. These children did not have the institutional shield of Whiteness
in agencies charged with determining their “appropriate” care.
And then, there was the matter of my uncles. My mother’s brothers
all came of age in the 1960s, a turbulent time for young Black men in
Oakland. My uncles found themselves in the middle of Black Power and
civil rights movements, and also in new drug markets targeting unem-
ployed Black youth, followed by the launch of the War on Drugs. My
grandparents and I knew that at any moment a police cruiser could pull
up in front of our house, looking for my uncles James, Bubsie, or Billy.
More than once my grandparents got late-night calls from the precinct
where my uncles were jailed on drug charges. And Bubsie, who suc-
cumbed to psychosis during drug-induced confrontations with police,
died in the state mental hospital to which he was mandated after biting
off someone’s earlobe.
My coming of age was marked by race and by drugs. I was the prod-
uct of my mother’s short-lived marriage to a Norwegian man who
returned to Norway without her after two years as a UC Berkeley stu-
dent at the end of the 1960s. Although I knew that the one-drop rule,
written into US law a century ago and still an American cultural prac-
tice, defined me as Black, I was also aware from an early age that White-
ness is relative. My mother lied about our address to get me into the
predominantly white “high-performing” public primary schools out-
side of our residential district. I saw my teachers bristle when my dark-
skinned mother attended parent-teacher night, a dark fleck against a sea
of white parents. My teachers relaxed around my less threatening light-
brown freckled face and the perfect grammar that my mother taught
me. I learned to weave my way in and out of places that were too white

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 Pharmakon of Racial Poisons and Cures   |   17

for my mother and to participate in white conversations, playing up my

ties to Norway with the white girls who studied magazine photos of
royal European families at recess.
Through high school, I covered myself in loose clothing and rejected
cigarettes, alcohol, and drugs, in fear that I’d be mistaken for the drug-
and sex-crazed mulatta whore of American movies. In my mind, my
abstinent image, along with the grammar of my speech, provided a
measure of Whiteness that could protect me against racial violence. I
had learned what a liability drugs were if you were Black; I knew that
drugs could blacken you if you were not fully white but that if you were
white, drugs were the marker and the benefit of your Whiteness.
Decades later, after I’d finished medical school and a psychiatry resi-
dency and was a research fellow, I was at dinner with my advisers and
passed on wine as I usually do. We had been discussing the abstinence
required by twelve-step programs, and one of them turned to me, say-
ing, “I notice that you never have wine!” I suddenly realized that they
thought I was in recovery myself. How ironic, I thought, that for me to
have a place in the white world of health research, in their minds and in
my actions, I had to be in recovery. And at the same time, being in recov-
ery was a reflection of my blackness: in the minds of my advisers, being
not-quite-white gave me the potential for uncontrollable substance use.
Writing this book forced me to articulate something that I had not
talked about before: my own Whiteness. When I show up to the clinic
or the classroom as a doctor, rather than a patient, I am stepping into a
white role. The confidence with which I sign my name on a prescription,
or call an insurance administrator to debate denial of coverage for my
patient, or submit a manuscript to a health research journal—these are
white actions taken from a white position in the social hierarchy. When
I stop at a motel while driving across country and my husband asks me
to check us in, knowing the legacy of racial terror that for over two
centuries prevented Black men from traveling freely through white
spaces, I tap into a form of Whiteness that is closed to my husband.
And then there are moments when I see how Whiteness skips over
some white people. For instance, along with everyone in my clinic’s video
therapy group, I adopted Tim as one of my own. Rail thin with a tooth-
less smile, having spent decades on the streets, Tim did marvelous pho-
tography, but he barely spoke. Over time, with gentle nudging, we dis-
covered that his singular passion was the music of David Bowie. It was
the music he had heard as a teenager in the 1970s when his stepfather
turned him out and he had to find his way around the world from rural

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 18   |   Technologies of Whiteness

Pennsylvania. At a karaoke party to celebrate recovery, we conspired to

dress Tim up as David Bowie, replete with a full face of glam rock glitter
makeup, a red wig, and a space suit. Strumming his air guitar and croon-
ing “Ground control to Major Tom,” Tim was David Bowie.
Months later I invited him to speak to my class of college students
about recovery. He started by saying, “I came here because of Dr.
Hansen. But I don’t have anything to say.” I showed the video of Tim
as David Bowie, and Tim described his journey from sleeping in the
Pennsylvania woods, to hanging out on the city park benches where
police officers kicked him in the mouth, to starring in Bowie’s “Space
Oddity.” All the while, he apologized for speaking instead of me, since
I was the professor. And I understood that in the United States, where
race is intertwined with class, there are times that I am whiter than
some white people.
Whiteness, as a system, does not include all white people, and this is
by design. Travis Linnemann, a sociologist who studied the white people
in rural America who were caught up with crystal methamphetamine in
the 1990s, explained this when we met at a drug policy conference. At
the time, he was teaching at Eastern Kentucky University and document-
ing how poor white Appalachians were incarcerated, and their children
put into foster care, at ever higher rates even after the “kinder, gentler”
national drug policies that followed media coverage of opioids in subur-
ban white America. Travis had interviewed policy makers and analyzed
media coverage of drug use in the predominantly white, rural states of
Kentucky and West Virginia, finding that the way they described poor
whites who used drugs—in terms of cultural depravity, laziness, inclina-
tion to have too many children, and violence—was similar to the ways
Black and Brown people were described in parts of the country that
were less white. The racial images deployed in drug policy are about
justifying inequality, Travis said. In places where poor whites are the
“other,” poor whites play honorary Blacks in our national theater of
drugs and blame.
The mark of Whiteness as a system, rather than a quality of individu-
als, is that those who inhabit a white position do not dictate the form
their Whiteness will take. White doctors who want to prescribe medica-
tions for Black patients but cannot, because Black patients do not have
the right health insurance, and white pharmaceutical executives who
use stereotypes of middle-class white consumers as at lower risk of
addiction to get around regulators, do not choose the terms of White-
ness. I do not control the forces shaping my Whiteness relative to my

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 Pharmakon of Racial Poisons and Cures   |   19

mother and my husband when I use it to get an education or reserve a

motel room. Whiteness, as an overarching mechanism that preserves
the American hierarchy, sweeps individuals up in its path: participation
often feels mandatory and is often unconscious. Only through sustained
and collective action can white people, and people of color, push back
against the Whiteness that overdetermines our health care system, our
drug policies, our overdose deaths, and our social order.
• • •

Thirty invited researchers arranged themselves at the National Institutes

of Health (NIH), in the personal conference room of its director, Francis
Collins. I was seated to Collins’s far left. A panel of four social scientists
presented national data on opioid overdoses and their correlates. Paus-
ing on a graph of mortality by race, one of them commented, “Whites
are just not making progress. This is very disturbing.” As she listed other
variables that predicted white mortality, such as being out of the work-
force, never having been married, having children out of wedlock, and
lacking a sense of social connection, her co-presenter chimed in: “It’s not
just current wages. It is . . . not knowing your kids, the decline in stand-
ard of living from one generation to the next.” A participant asked why
whites were disproportionately dying prematurely under those condi-
tions, given that Black and Latinx people had also experienced the
decline in US manufacturing jobs. In response, the last panelist stumbled
over his words, and landed on religion. Blacks had churches, he rea-
soned, and that might be protective against overdose.
Barely able to contain myself, I raised my hand. “I suggest we need a
more nuanced understanding of how racism works,” I proffered:

It’s not that religion is protective, it’s that Black life expectancy has been a
decade lower for half a century. The classic quote from the 1990s is that a
Black man in Harlem has lower life expectancy than a man in Bangladesh.
What we see in unemployed whites now happened to Blacks forty years ago.
Postwar gains in working-class standards of living were lost decades earlier
among Blacks, who were last hired and first fired in manufacturing, excluded
from segregated unions. What about heroin injection–related HIV epidemics
and drug war policies driving mass incarceration that wiped out a generation
of Black and Latinx people over the past three decades? What about the cur-
rent statistic that Black men are now experiencing the fastest increase in
opioid overdoses? What kinds of data do we need to explain this?

I was met with silence. The “deaths of despair” discourse that the
panel employed was geared to whites, not Blacks, and could not absorb

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 20   |   Technologies of Whiteness

the realities of the earlier, Black epidemic of heroin that had been repre-
sented in 1970s US media as a crisis of crime, rather than a crisis of
public health. The concept of “deaths of despair” was spearheaded by
Princeton economists Anne Case and Angus Deaton, who published a
widely cited article just before the 2016 presidential election reporting
that the life expectancy of US whites had fallen by five years over the
past two decades, while the life expectancy of every other ethnic/racial
group—except Native Americans—had risen. They found that the pri-
mary cause of premature white death was drug overdose, followed by
cirrhosis of the liver and suicide, and they pointed to chronic unemploy-
ment among blue-collar whites in the Rust Belt of former manufacturing
and mining towns across the midwestern US as a cause.17 Their conten-
tion that community-wide unemployment led to disintegration of social
networks and thus to opioid use and overdose was supported by socio-
logical studies finding community-level correlations of high overdose
rates with low levels of social connectedness.18 This argument made
sense to me, having witnessed so many people come to my hospital for
addiction treatment who had long been unemployed, disconnected from
the formal economy and from sober people. But their humanizing, soci-
oeconomic argument contrasted with demonizing media images of
addiction prior to the opioid crisis: of criminal, menacing “junkies” of
1960s-’70s Black and Latinx inner cities that had fed white anxiety and
flight from cities to the suburbs, and of violent drug-dealing “super-
predators” and oversexed “crackheads” in those same neighborhoods
from the 1980s-’90s that had led to mandatory-minimum drug sentenc-
ing and the acceleration of racially targeted mass incarceration.19 The
major distinction of the opioid crisis from prior narcotic epidemics was
the perceived Whiteness of contemporary opioid use.
The deaths-of-despair socioeconomic explanation for the (white)
opioid crisis peacefully coexisted at this NIH meeting with what might
have been a competing frame: that of neuroreceptor-level biological vul-
nerability. NIH director Francis Collins convened our meeting by
reviewing the priority that the NIH gave technological breakthroughs
such as injectable buprenorphine, now formulated as six-month-release
probuphine, which had emerged from an NIH collaboration with a pri-
vate biotech firm. He cited the President’s Opioid Commission Report
of November 2017, which advised that “the NIH begin work immedi-
ately with the pharmaceutical industry to develop novel technologies.”20
His agency fostered public-private partnerships and met with pharma-
ceutical industry leaders to define scientific opportunities. The main

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 Pharmakon of Racial Poisons and Cures   |   21

goal, from Collins’s point of view, was to “enhance the range of medical
options to treat addiction and prevent overdose,” and our job at this
meeting was to help develop “precision medicine” by finding the “psy-
chosocial components to improve the effectiveness of MAT (Medication
Assisted Treatment) [and] predict which individuals will respond.”21
Yet the apparent contrast between the deaths-of-despair explanation
for the opioid crisis and the brain disease explanation for opioid deaths
belied that the two operated with parallel ideologies of Whiteness. On
one hand, in addition to gesturing toward a nostalgia for an American
industrial past in which the white working class shared the fruits of the
racial hierarchy with white elites, the fact that “deaths of despair” were
visible among white but not Black opioid users signaled that despair
was a racially coded way of humanizing addiction, of placing blame for
addiction outside of the affected individual. As we detail in this book,
the racial coding of despair is apparent in the ways people with opioid
use disorder are represented in the media and in historical and geo-
graphical comparisons of drug policies by race and class.
On the other hand, the very idea of individual biological vulnerabil-
ity to substance use disorders is racialized, implicitly, in brain disease
models of addiction. Locating addiction in molecular interactions in the
brain abstracts it from the social identity, neighborhood conditions,
institutional resources, and regional drug policies of the affected person.
Then, in the US, the abstract, universal, standard human of clinical
studies has been imagined to be the proverbial “70 kg white male.”22
White men have long been the normative patients, the unmarked
humans, and other humans (such as nonwhite people, women, or non-
binary people) have had marked status as variants in the symbolic hier-
archy. As we detail in this book, the chronic brain disease model of
addiction widely adopted by researchers and federal agencies, including
the NIH, in the 1990s and 2000s was pivotal in changing the racial
associations that government regulators and clinical practitioners made
with consumers of opioids, with their risks of addiction, and with their
medical need for treatment as opposed to legal intervention. Whiteness
is the key to decoding shifts in drug regulation, drug policy, and clinical
standards of addiction treatment at the turn of the twenty-first century.

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