RICHMOND, Va. — Darryl Cousins counts three friends who have died of an overdose in the past two months.
Some were folks he had used with years ago when he was in active addiction. Others he tried to help in his role as a counselor at several recovery houses in the East End.
“You get three or four deaths, maybe in a week now, in Richmond, Henrico and Chesterfield, instead of one or two a month,” Cousins said. “There’s not that much light being shed on the situation.”
The sharpest spike has been in Virginia’s Black population. In the past four years, the state has seen opioid overdose deaths among Black Virginians more than triple — the highest death rate, by far, of any demographic. The numbers underscore the lethality of a fentanyl-polluted drug supply, as well as structural barriers to entering recovery — a critical first step in preventing fatal overdose.
The numbers — made publicly available by the Centers for Disease Control and Prevention death certificate database — tell the story of a striking rise, particularly in the Richmond metropolitan area. Chesterfield County had 34 deaths in 2021, up from 11 in 2018. Henrico County spiked similarly, up to 44 deaths from 14, and Richmond accounted for 135 deaths, up from 41 deaths in 2018.
The spike was more acute in Richmond than in any other county in the state.
“It desensitizes you to death,” Cousins said.
Cousins, a Black man, works for Starfish Recovery and Wellness, a Richmond-based recovery residence for people with addiction. He was born in Richmond’s South Side, where he went to George Wythe High School. He’s been sober for 15 years, he says, and shares a long view on how the city has changed in that time. Most frightening is the drug that seems to be everywhere these days.
“All of a sudden it’s in every drug being sold,” Cousins said. “Fentanyl has taken over the drug world.”
76% of fatal overdoses
Fentanyl, a synthetic opioid developed in the 1950s for severe pain management, has run over the illicit drug supply.
At 50 times the potency of morphine, it is deadly and easily overconsumed in a powder format.
The drug delivers a stronger version of the same full-body euphoria associated with heroin. At the same time, it depresses breathing in the lungs to dangerously low levels, starving the body of oxygen.
“This explains why fentanyl is so deadly: It stops people’s breathing before they even realize it,” said Dr. Patrick L. Purdon, senior author of a study on fentanyl’s lethality conducted by doctors at Massachusetts General Hospital and published in August.
This year, Virginia epidemiologists linked the drug to 76% of fatal overdoses in Virginia. Each day, more than five Virginians die from an overdose explicitly linked to fentanyl.
Medical examiners have come to expect fentanyl, often finding it commingled with the drugs that used to be considered the most deadly — such as heroin, cocaine and methamphetamine.
Overdoses from those drugs have jumped, too, but now, four out of every five cocaine overdose toxicology reports finds fentanyl played a role as well.
What’s also frightening is how the drug is being sought out, Cousins said. Active drug users seek out fentanyl-laced heroin, he said, because their bodies have normalized heroin in its more regular form.
“I was trying to get a grip on it, too, I was trying to understand, why would you go looking for something that literally takes you to the brink of death?” Cousins said.
Tisha Wiley, a researcher with the National Institute on Drug Abuse, says the road to today’s opioid crisis in the Black community has been paved by historical racism in health care.
As white patients were readily prescribed drugs like OxyContin in the late 1990s and early 2000s, Black patients found it far harder to convince doctors of the legitimacy of their pain, Wiley said.
“One of the things that we hypothesized early in the pandemic was that Black patients were less likely to get prescribed pain medications, which would translate into Black patients having a harder time getting prescribed medications” for opioid use disorder, Wiley said. “That comes down to implicit bias.”
The practice continues in 2021, according to a recent study published in the New England Journal of Medicine, and has worrisome second-order effects.
Patients in pain shopped for doctors more willing to write prescriptions, or cheap street substitutes, like heroin.
The bias, Wiley said, also appears when Black people with addiction seek medically assisted treatment for addiction, such as drugs like methadone, an FDA-approved opioid used to taper down cravings.
And while white people with addiction are more likely to get diverted into treatment, such as rehab, Black and Hispanic people with addiction are more likely to be arrested, Wiley said.
That’s made jails a key focus for reducing, and equalizing, the opioid epidemic.
Resources needed to recover, such as housing and insurance, also skew along racially divided lines. Walter Randall, a recovery facilitator at High Council Services, said Richmond’s premier recovery residences target what he described as “a white demographic”: patients with private insurance or the ability to pay out of pocket.
Many don’t take Medicaid, said Randall, who is Black and has been in recovery for 22 years. He says the downwind effect of that choice has been a segregated recovery space.
“White people have McShin, True Recovery, Starfish,” Randall said.
“Black people have” Narcotics Anonymous and the Community Services Boards.
Jimmy Christmas, a licensed therapist with River City Comprehensive Counseling Services, which offers substance abuse and mental health services in Richmond, said some of those divisions are blurring as the opioid epidemic in the Black community has received more attention.
“When I look at what the white community has had access to, this physical apparatus of recovery homes, compared to the Black population — it makes me sad to even look at that,” said Christmas, who is Black and in recovery. “I’m sitting here and watching our country fail.”
Community buy-in
Christmas says that Richmond’s Black community needs “guerrilla outreach,” not only to warn about the lethality of fentanyl, but to build community buy-in that recovery works.
“What’s lacking is some of these pockets, like the East End, need more outreach,” said Christmas, who is 61 and has treated generations of people with addiction in the Richmond area.
“For 20 or 30 years in the white community, there have been white families willing to pay for their loved ones’ treatment. I would like to believe that there is a pocket in the Black community that is willing and capable to pay for their treatment, too,” he said.
Christmas said recovery residences, the “gold standard” in addiction treatment, cost about $5,000 a month — a price tag that can be prohibitive without a family to foot the bill. And most have white owners and staff, he said.
But increasingly, more funds have become available for state legislators and health agencies. Across several grants, Virginia has already received more than $70 million in federal funds meant to support recovery services. Those funds have been critical in removing financial barriers that have entrenched the racial divide in access to care.
Grant money helped the Virginia Association of Recovery Residences to diversify its clients by creating a fund for indigent clients.
Recent data shared by the organization shows that more than 40% of admissions are for non-white individuals.
Millions of dollars have also been directed to prisons and jails, which have begun to deliver medicated withdrawal treatments to inmates with opioid use disorder.
But the lion’s share of incoming funds earmarked for curbing the opioid epidemic in Virginia has yet to be distributed. That money, approximately $610 million, will come from distributors and manufacturers of opioids, such as Purdue Pharma, Janssen Pharmaceuticals and others.
Recipients, such as the city of Richmond, will decide how it should be used.
Jim Nolan, a spokesperson for the city, said decisions about the money would be made in the coming weeks, pending an appropriation process and approval of the mayor and members of the City Council.
The city is set to receive at least $4 million over 16 years, according to records shared by the Virginia Attorney General’s Office, which is shepherding the funds to Virginia localities from distributors.
