Abstract
In the United States, fascination with drug use parallels almost equally with a fascination with drug prohibition. The War on Drugs established a new fixation on the latter, which has been reinvigorated since the turn of the millennium introduced a new generation of opioids to the country. No longer a mysterious substance to be smoked in opium dens, the pill form of oxycodone promised a new phase of pain management. A complex web of factors prevented the pill from serving as a true panacea for pain patients. In their book Whiteout: How Racial Capitalism Changed the Color of Opioids in America, Helena Hansen, Jules Netherland, and David Herzberg deftly contextualize the role systemic racism plays in drug use and prohibition.
In the first half of the book, the authors take the opportunity to introduce their individual perspectives on opioid use and prohibition. The first chapter – anchored by anthropologist/psychiatrist Helena Hansen – introduces the reader to the concept of the pharmakon: opioids as both a medication and as a poison. She uses anecdotes from her time as an addiction-focused clinician to illustrate her growing realization that specific drugs (namely, methadone and buprenorphine – two medications to treat opioid addiction) were introduced to the market with unspoken but clearly understood racial undertones. This introduction to the deep nuances of racially situated drugs serves as a throughline for the rest of the book, particularly in the cognitive dissonance of the same drug being a medication for white people and an illicit substance for everyone else.
Following Dr. Hansen's introduction to the book's premise, the three authors collaborate on the next chapter which delves deeper into the racial divides surrounding opioids. This chapter is carefully organized around the four primary technologies that carve out a space for white patients to legally acquire and consume opioids. In the interdisciplinary nature of the book, sociologist Jules Netherland contributes the next chapter with a description of her experience with drug-related public health and advocacy work – an excellent parallel to Dr. Hansen's retelling of her clinical work in Chapter 1. Across a variety of policy initiatives, Dr. Netherland is left with the conclusion that discourse on public health gains traction with legislators when the ‘public’ in question is white. Rounding out Part One of the book is historian David Herzberg's Chapter 4 retelling of a variety of drugs that held American attention since its founding. Much like states are laboratories of democracy, Dr. Herzberg maintains that “[t]he past is a laboratory of human endeavor” (Hansen et al., 2023), and can help build the roadmap to a better pharmaceutical future based on the mistakes and successes of the past.
Unlike Part One, the chapters in Part Two are not designated by their author, indicating to the reader that the book has established three of the many disciplines invested in drug research and moves forward in the true spirit of interdisciplinary collaboration. The first three chapters in Part Two delve into three specific opioids and their ‘racial biographies.’ First, the authors detail Purdue Pharmaceuticals’ OxyContin and its FDA approval during the same time period as the pain management movement in the United States. Marketing materials for this opioid (photos of which are included in Chapter 5) exhibit a focus on white, suburban grandparents and military veterans, while Purdue surgically threaded the needle that split ‘trustworthy’ patients from ‘abusers,’ and ‘true addiction’ from ‘pseudoaddiction.’
As a natural follow-up, Chapter 6 examines a quintessential pharmakon: buprenorphine, an opioid medication prescribed to treat – among other things – opioid addiction. Dr. Hansen lends her significant experience in clinical addiction work to this chapter and helps describe buprenorphine's stark departure from methadone (another opioid used to treat opioid addiction). The latter is part of a surveillant, stigmatized treatment regime while the former successfully returns white drug users to their ‘normal’ life. For those not able to access buprenorphine, Chapter 7 details the meandering journey of heroin in the United States, and the most recent influx of white, suburban users. As Purdue successfully made OxyContin less abusable, opioid addiction that had already taken root sought replacements for prescribed drugs, finding heroin an acceptable substitute. This chapter illustrates the benefit of including history as a drug research discipline: the shifting perceptions of heroin use across time and across races is a gripping yet somber read.
The final chapter is a welcome dose of hope in the form of specific policy recommendations, bolstered by case studies of treatment successes outside the United States. By no means a wholly cheerful ending, Chapter 8 compares these international successes to negative outcomes due to lack of access to treatment domestically. The authors provide readers with a numbered list of action points to ameliorate the opioid crisis in the United States, followed by a personalized list of takeaways from each author's respective field.
The authors lend their combined expertise even beyond the two primary sections of the book to provide quick reference points for readers. Before Part One begins, the book provides a timeline of opioid use in the United States, which manages to condense over a hundred years of drug use and prohibition into a single page, from the introduction of smoking opium to modern-era fentanyl use. After the final chapter, the reader can find a comprehensive glossary of drug-related terms. Much like lawmakers clearly define important terminology germane to the legislation at hand, the authors help to establish a communal set of language to further conversation and research.
As with any collaborative work, Whiteout covers wide-ranging perspectives and ideas. This book is not immune to some amount of overlap and repetition, but this serves to reiterate the most salient points the authors prioritize as a team. It is abundantly clear that the three authors provide this book as a means to share their lived experience with the larger conversation surrounding opioids. Any reader – academic or otherwise – who has ever wondered about why opioids seem to have hit white communities harder is an ideal audience for this book.
Whiteout's authors put words to the often-unspoken connection between opioids and whiteness, with too-familiar instances of past ‘white’ drugs taking hold in the United States. The primary takeaway (situated in the book's coda) for readers is reflected in the very organization of the book's authorship: that multi-discipline, collaborative work is the solution to mitigate the damage of the opioid crisis. Three researchers from distinct disciplines came to the same conclusion: that better understanding of the role of whiteness in drug research is an essential next step in loosening the grip of opioids on the United States.