Substance use disorders (SUDs) continue to rise across the United States, yet Black patients routinely face persistent, deeply entrenched disparities in clinical diagnosis, treatment access, and pain management. These long-standing inequities around drug use and substance abuse color how treatment and support are doled out. Historical biases, socio-economic disadvantages, and unequal healthcare infrastructure leave many people without care.
Instead of essential medical support and harm-reduction interventions, many people are criminalized rather than cared for. While policymakers are still considering ways in which the War on Drugs failed, the goal remains to reduce overdose deaths and long-term dependency.
To counter this escalating public health crisis, clinicians must actively learn to recognize the signs of opioid misuse and substance use disorders through objective, evidence-based methods rather than subjective observations.
Examining how implicit bias directly influences prescribing patterns is a critical step toward meaningful change. By adopting practical, standardized screening strategies and fully embracing comprehensive harm-reduction protocols, providers can deliver equitable, compassionate, and life-saving care for all their patients.
Substance use disorders continue to rise, yet Black patients often face disparities in diagnosis, treatment access, and pain management. Because the underlying neurobiology of addiction remains uniform across all human demographics, the stark differences in real-world health outcomes are driven primarily by external clinical and social factors.
SUDs are chronic, relapsing medical conditions characterized by a problematic and compulsive pattern of substance use that leads to clinically significant impairment, distress, and health complications. These disorders are often seen as moral failings, when science has proven that addiction actually alters fundamental brain circuitry over time. Neurobiological pathways responsible for reward, motivation, memory, and impulse control are affected.
Opioids, which include prescription analgesics, synthetic compounds, and illicit substances, fit directly into this pathology by binding to specific mu-opioid receptors in the central nervous system and gastrointestinal tract.
Muting pain signals and flooding the brain with massive surges of dopamine, opioid drugs create a high potential for physiological dependence, severe withdrawal syndromes, and addiction.
Bih Bikelle, MD, APBN, Associate Medical Director at Greenhouse Treatment Center, emphasizes the highly uneven and inequitable impact of this expanding epidemic. “To better recognize signs of opioid misuse and substance use disorders in Black patients, clinicians should actively address the impact of systemic bias and evidence-based assessment rather than subjective judgment,” she explains. “Black patients are more likely to have pain undertreated or to be incorrectly labeled as ‘drug-seeking,’ both of which distort clinical recognition of SUD. Clinicians should use standardized screening tools for all patients and avoid relying on assumptions about risk based on race or appearance.”
Biases distort clinical recognition and severely delay necessary care. Clinicians can hone in on precise physiological indicators of acute opioid use and withdrawal. For example, pinpoint pupils can strongly suggest active opioid use, though patients using their legal prescriptions responsibly may also present with this same clinical finding. This sign may be a potential clinical indicator if the individual is not supposed to be receiving opioids.
Conversely, observing a patient with dilated pupils in a well-lit room, goosebumps, frequent yawning, and a runny nose is highly suggestive of opioid withdrawal. These physical cues should immediately prompt a compassionate, objective clinical inquiry rather than judgment.
Alex Boutselis, MD, Medical Director of Overdose Lifeline, highlights the national screening standards required for modern equitable practice. “The U.S. Preventive Services Task Force recommends routine screening for unhealthy drug use in all adults when appropriate diagnosis, treatment, and referral services are available,” he explains.
Dr. Boutselis lists other validated instruments, such as the National Institute on Drug Abuse (NIDA) Quick Screen and the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) tool, which make objective, universal screening achievable in any standard clinical environment. Furthermore, checking the state’s electronic Prescription Drug Monitoring Program (PDMP) before patient visits should become a non-negotiable part of providers’ workflow.
“Not uncommonly, you’ll find patients repeatedly filling prescribed narcotics, including opioids, earlier than they’re supposed to,” says Cooper Stone, DO, Clinical Assistant Professor of Psychiatry and Behavioral Science at Perelman School of Medicine at the University of Pennsylvania. “You may also see on the PDMP that they are paying cash for some of the scripts, filling scripts at multiple different pharmacies in quick succession, and getting prescribed the same or similar medications from multiple prescribers who aren’t aware of one another.”
Dr. Stone says physicians also need to ask their patients directly if they are under the influence or abusing substances like fentanyl, heroin, or other addiction-causing drugs. “Sometimes it’s the least suspecting patients that come to surprise us all. You won’t know if you don’t ask!”
“There are a lot of patients out there who are struggling, and substance use doesn’t care about the color of your skin,” Dr. Stone says. “Addiction doesn’t discriminate. Bias means people who could otherwise stand to benefit aren’t getting properly identified or getting the help they need. That’s a real problem.”
Implicit and explicit biases hurt everyone. These inaccuracies alter medical prescribing behaviors and treatment pathways, creating disparities in patient care and safety. When a clinician views a patient through a lens of racial suspicion rather than clinical medicine, identical behaviors are interpreted differently. A 2025 study led by researchers at UCLA found that “Black emergency department patients [are] less likely to be treated with opioids – and more likely to misuse them later as a result.”
Pain relief medication is a complex situation, as patients face a serious risk of being labeled “non-compliant” when advocating for themselves. Yet, Black patients have also reported the need to self-advocate for adequate medical care and treatment, and this is often after overcoming the “Superwoman” trope and the structural barriers to access, which can cause Black patients to delay preventive care, only to seek treatment for more advanced stages of illness and more acute pain.
Over time, experiencing these systematic disparities, shorter consultation times, and lower-quality communication severely erodes patient trust.
Modern clinical medicine strongly prefers the term “medications for opioid use disorder” (MOUD) over “medication-assisted therapy” (MAT) because therapies like buprenorphine, methadone, and naltrexone are the primary treatment for the biological disease, rather than a secondary supplement. Despite overwhelming clinical evidence that MOUD dramatically reduces illicit opioid use and prevents overdose mortality, access to these medications remains deeply and structurally unequal.
Black patients are less likely to be offered MOUD early in their diagnosis or to be consistently referred to specialized care programs. This treatment gap is widened by severe structural, financial, and social barriers that impede patients’ recovery.
Dr. Boutselis points to a recent study that found that of more than 176,000 opioid-related health care events, Black patients had a 17.1 percent chance of receiving buprenorphine to treat opioid use disorder, compared to 20.5 percent of white patients — a gap that persisted even after adjusting for insurance and other likely factors.
Dr. Bikelle also explains the widespread misconceptions that halt patient recovery. “Stigma also plays a major role both in the community and within healthcare settings where MAT is still incorrectly viewed by some as ‘replacing one addiction with another,’ he explains. “This misinformation can discourage patients from initiating or staying in treatment.”
MOUD prescribers may also be hard to find or access for some patients, as not all physicians are trained or authorized to prescribe them. The FDA has created a campaign, Prescribe with Confidence, that offers evidence-backed supports, training, mentoring, reference guides, and peer-to-peer connections available to help providers who are currently prescribing these medications or who hope to start.
At the practice and institutional levels, clinicians must actively embrace harm-reduction tactics to save lives immediately. Clinicians should routinely provide Naloxone prescriptions (or share pharmacies that sell the medication over the counter) to all at-risk patients and their immediate social networks, alongside transparent discussions regarding the utilization of fentanyl test strips and connections to.
Dr. Boutselis stresses that true equity requires internal accountability and continuous monitoring of metrics within healthcare networks. He says universal screening is fundamental. Consistently asking patients the same questions, regardless of assumptions about risk, is critical to mitigating bias.
“Safety tools like prescription drug monitoring checks and toxicology testing should be applied consistently and explained clearly to patients in a way that they don’t feel singled out,” Dr. Boutselis explains. “When opioid use disorder is identified, the goal should be same-day treatment or a direct, personal handoff to a provider — not just a referral slip. Naloxone, the overdose-reversal medication, should be offered routinely to at-risk patients and their close contacts.”
Providers could also discuss practical harm-reduction steps, including fentanyl test strips, and connect patients with legally authorized community harm-reduction resources, including sterile-use supplies where available. “Finally, health systems need to track their own outcomes by race and ethnicity because you can’t fix a gap that hasn’t been measured,” Dr. Boutselis says.
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