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Mortality among white men in the United States is increasing. This epidemic is one of the primary reasons and racism and the “man-box” are at the root the problem.

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Brandon* had an idyllic childhood. He had loving parents, good relationships with his siblings, and a home in one of the well-appointed suburbs of Chicago. He was an athlete, well-liked among his peers, who enjoyed his high school experience. After graduation, he stayed with his high school sweetheart, went to welding school, and studied marketing. He was grateful for his middle-class upbringing, which had opened doors for incredible opportunities. To outsiders, Brandon’s life looked like it was on a trajectory to White Picket Fence success.

In 2013, Brandon was arrested after fleeing on foot from a beat cop on the West Side of Chicago. It was his first arrest. Police found 93 bags of heroin on his person — 35.1 grams in total.

“I was spending $900 on heroin every two days,” Brandon told me, shaking his head. We were eating fried chicken in my Chicago office, where I usually meet with counseling clients. Our interview was scheduled in response to a simple question I had posed on Facebook: “Why are white men dying of heroin?”

Brandon messaged me in minutes: he wanted to help. We scheduled time to meet after work.

“Heroin addiction is affecting men and women at epidemic levels,” I started. “And still, there’s reason to wonder how, internally, this is specifically playing out for men.”

“Men don’t want to admit to being unable to do something on their own,” he said. “The stigma is so negative that you don’t want to reach out for help, until you reach the point that you’re almost beyond help.”

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Brandon realizes just how lucky he is — to be alive, out of jail, and in recovery. The court mandated him into intensive drug treatment, methadone maintenance therapy, and court supervision — a punishment that saved his life.

White Mortality Skyrocketing

Even as mortality among developed countries is decreasing, the mortality of white men and women in the United States is increasing. A study published in September 2015 by Nobel laureate Deaton Angus and Anne Case examined trends between 1999 and 2013 to reveal a startling disparity: among white Americans (and no other subgroup in this country), mortality is actually increasing. The cause: drug and alcohol overdose, suicide, chronic liver disease, and cirrhosis. Morbidity trends, measuring quality of life, also revealed that unprecedented numbers of white Americans report debilitating physical pain.

This is a crisis. Deaton and Case put it into perspective: “If the white mortality rate for ages 45–54 had held at their 1998 value … half a million deaths would have been avoided in the period 1999–2013, comparable to lives lost in the US AIDS epidemic through mid-2015.”

Media outlets were quick to assign blame to the causal role of the American economy. Americans sense the crushing loss of socioeconomic mobility. Middle class families are fighting to stay in the middle class. The lingering effects of the Great Recession — such as lost savings, long-term unemployment, cuts to public services and pensions, and devalued housing — remain acutely felt. Compellingly, the argument for blaming the economy rests on the conclusion that the American Dream is, in reality, the American Myth.

But economic issues can’t begin to explain the increase in self-reported measures of physical pain– until we consider how physical pain is a narrative of subjective distress. Doctors have the most influential hand in shaping that narrative. This story starts with a prescription pad.

Pain Pills—The Real Gateway Drugs 

Brandon dreamed of becoming a professional wakeboarder, and practiced every weekend during the summer at his family lake house. Brandon was 25 when he suffered a wakeboarding injury to his shin. His orthopedist sent him straight to the operating room, where surgeons severed his shin muscle in half, relieving dangerous muscle pressure.

“My orthopedist said it was the worst pressure he had ever seen,” Brandon said.

After the surgery, Brandon couldn’t walk. He was ordered to 10 days of bed rest, with the promise of eventual physical therapy. The doctor told Brandon he was lucky not to have had his leg amputated.

“I would look at my leg and think, ‘I know how to walk. Just take a step.’ But I couldn’t make my leg work,” Brandon said.

From dreams of being a professional athlete, Brandon was rudely awoken to the reality of being dependent on others and in constant pain.

His doctor knew how to alleviate the pain. Out came the prescription pad and an order for Vicodin. Brandon was familiar with the protocol. As an athlete, he had weathered years of sports-related injuries with prescription opioids as the primary intervention.

“Doctors never thought twice about prescribing me Vicodin or codeine. They would prescribe more than I could even use in a month,” he said. “And the message was always, ‘Just take them until you feel better.'”

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The problem, though, was that the pain of his injury was both physical AND emotional. The feelings of defeat, incompetence, and disappointment were overwhelming. As an athlete, Brandon prided himself on being the kind of guy to “brush stuff off” – to not let things get to him. And so, when confronted with the flood of negative emotions, Brandon numbed them.

“That was when I started abusing Vicodin,” he said. “I would lay on the couch and take 10 of them — just get melted.”  After several months, his doctor realized that Brandon was chemically dependent — that his self-reported pain was psychological. After all, Brandon could walk again. The doctor cut him off of Vicodin, cold turkey. “I was like, ‘Are you kidding me? I’m still in pain.'”

Prescription dwindling, Brandon isolated himself at home, hoping to figure out a solution to his problem. He took the remaining pills to numb out a sense of despair; he didn’t want emotions getting in the way of problem-solving. It seemed like a personal issue, and he had always prided himself on taking personal responsibility seriously. He was alone, and in despair.

The Role of Gender in Addiction

Beneath that sense of despair, there are deeper threads connecting men in addiction.

I became aware of the ManKind Project (MKP) several months ago. A male colleague told me to “check it out” after hearing from friends who had gone through the New Warrior Weekend — a retreat for men that encourages them to develop inner strength and emotional integrity. Amazed, (and suspicious), my colleague described the transformation he saw in his friends: they left unhealthy relationships, reduced their problem drinking, took care of their bodies, spent time with friends, and felt a renewed sense of purpose.

“What if it’s a cult?” my colleague asked. “It sounds too good to be true.”

Interest piqued, I did my homework. It was my turn to feel surprised: the transformation these men experience in the MKP isn’t based on religious principles, spiritual doctrine, psychotherapy, or personal zealotry — it’s based on community. No magic tricks or shell games — just community.

I’ve been a fan and follower ever since. After reading the Deaton and Case study, I reached out to MKP Communications Director Boysen Hodgson to get his thoughts. He is no stranger to the despair of addiction among men he encounters.

“Men have no sense of built-in purpose anymore,” Hodgson reflected. “Men need a sense of purpose, and feel they have lost it in the post-modern age. They go about their lives sensing this loss of purpose, but don’t know what is missing.”

White men, in particular, sense that the promise of being a man doesn’t exist today the way that it might have for the generations that came before them.

“I see the progress that our society has made because of feminism, civil rights, and social movements as essential evolution, an opportunity,” Hodgson said. “But a lot of men don’t have the self-soothing or coping skills to handle or integrate the perceived loss of status or power. So they act-out from a sense of victimization rather than integrating the current reality and seeing the opportunities in this new way.”

When faced with pain, for example, men tend to distract themselves, whereas women tend to draw on a range of self-care skills, such as reaching out to friends and family members, cognitive reframing, emotion-focused techniques, and positive self-statements.

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Masculinity, in many ways, is defined by the continual performance of competence – the ability to demonstrate ability – without requiring the aid or assistance of others. Hodgson recalls the many comments he has seen on the ManKind Project’s Facebook page: “They say, yeah, these guys must be a bunch of manginas.”

Women, however, are increasingly coping like men. I’ve noted elsewhere that women are gradually matching men in their rates of binge drinking, closing the long-held gender gap. And this makes absolute sense. After all, if we define masculinity as the performance of mastery, why wouldn’t high-achieving women mimic masculine ways of coping?

Historically, our society has viewed drinking and drug use as masculine behaviors. Hodgson perceives it as an offshoot of the masculine dichotomy: “Look at movies or TV shows, listen to conversations about manhood. Though there is positive change happening, with more kinds of masculinity being portrayed, the theme comes up again and again: Men are either objects-of-ridicule, or they are violent aggressors.”

Substance abuse fits the stereotypes of this dichotomy. Consider, for example, the pathetic skid-row drunk (object-of-ridicule) versus the violent, drunk husband (violent aggressor). Both are bad at coping. Both turn to substances. We recognize, with instant recall, the potency of these stereotypes, how easy it is to conjure up a visual. Both stereotypes support the notion that men act-out rather than skillfully self-soothe.

Without access to the self-soothing effects of Vicodin and his sense of purpose destroyed, Brandon turned to his friends, one of whom had a steady supply of his mother’s OxyContin—with her blessing. In the tony suburb of La Grange, his friend’s mother had tasked her son with selling her pills for cash. Brandon thus secured a seemingly endless supply of Oxys from a “safe” dealer—a white, middle-class mother.

Race, Class, and Access

“It was never hard to find pills in La Grange,” Brandon said. “We just went into our parents’ cabinets and there they were.”

I nodded. Brandon and I graduated from the same high school, in the same year. We both completed the ill-fated DARE Program in fifth grade. And although our social circles never crossed paths, his own description resonated with my experience. I recalled the free flow of prescription pills exchanged by teenage classmates. It was easy to break the law in our privileged suburb.

“I got away with everything,” he said. “Up until the point of getting arrested, no one had ever told me that I couldn’t do what I was doing.” He recalled a traffic stop when he was 17. The police officer questioned Brandon about the case of cold beer in the back seat of his car. Rather than arrest Brandon or issue a citation, the officer called his parents, encouraging them to ground him. The officer let Brandon drive away, beer case untouched.

“People think of La Grange, Burr Ridge, and Western Springs, and they think of this wholesome family area,” Brandon said.

“The hard line was never there,” I agreed. “Police saw us and thought to themselves, ‘These are good kids, just starting their lives.’ Which was code for white, middle class kids. That’s what they meant.”

The Racialization of Pain—A Narrative of Distress

Brandon’s case typifies the strange intersection of race, class, and gender in the current heroin epidemic. Most heroin users are white. Half of them started with prescription pain pills.

Doctors nationwide are more likely to prescribe opioid painkillers to whites than to their black or Latino counterparts—even when patients report the same levels of pain. A meta-analysis and systematic review of over 20 years of research shows that Latino patients are more likely than black patients to be treated with opioids for traumatic/ surgical pain, but less likely than white patients to be treated for non-traumatic/nonsurgical pain. Black patients were less likely than white patients to be treated for BOTH traumatic/surgical pain, and non-traumatic/nonsurgical pain.

My own experience working for a prestigious university hospital in Chicago bore that out. My job took me to rounds on every floor of the hospital, where I often heard doctors characterize their black or Latino patients as “drug-seeking,” “highly sensitive,” or “manipulative.” An even more coded, insidious form of speech manifested when floor doctors would curse emergency department staff for putting patients of color on IV Dilaudid before transferring them to the floor. I lost track of the number of times I heard doctors iterate the same frustration: “Now this patient is expecting Dilaudid. What was the emergency department thinking?”

Exasperated utterances cropped up when doctors discussed white patients on opioids, but the tendency I noticed was for doctors to urge a more gentle, compassionate perspective: “She’s been on painkillers for years. Her tolerance is up,” I heard a doctor say once.“This is a really hard situation. I want to treat her pain, but it’s hard to know what will be helpful.”

Few doctors will admit to this bias. And even though 85 percent of doctors feel that their peers overprescribe prescription opioids, an even higher percentage of doctors (88 percent)  feel confident in their own ability to prescribe appropriately.

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We could accuse doctors of being negligent or covertly bigoted, but that facile conclusion would blind us to the process of how the racialization of pain came to be.

Consider, for a moment, that pain is a clinical symptom, and cannot be observed as an “objective” sign (like a doctor testing a blood sample for cholesterol levels, or reading and analyzing an MRI). Clinical work requires that the patient and doctor create a narrative, using communication to facilitate an understanding.

Communication can fail on three levels: 1) The patient may not accurately represent their level of pain, 2) the doctor may not hear the patient’s words correctly, or 3) the doctor may give a different interpretation to what the words mean.

Even if the patient accurately describes their level of pain, the narrative value must resonate with the physician. And even the best doctors, who claim to be “colorblind,” rely on their cultural narratives of pain to make a clinical judgments. Racial stereotypes inform many of those narratives.

If doctors lack understanding for the pain of black and minority patients, it is likely because they are overwhelmingly white. Even though 13 percent of Americans are black, only five percent of practicing physicians are black.  Similarly, only five percent of practicing physicians are Latino. Since 1980, in fact, the number of practicing Latino physicians has actually declined by 22 percent – a stunning statistic given that the Latino population has increased by 243 percent in that same time period.

The overprescribing of pain pills to white Americans points directly to this racial disparity in medicine. And although physicians may be well-intentioned when they administer opioids to white patients,  the consequences have been deadly.

“Pain is the Fifth Vital Sign”

Our cultural narrative of pain starts with the pharmaceutical industry. In 1986, a study on the use of opioids in treating 38 chronic pain patients planted the seed of a new idea – what if opioids could be used more broadly? In spite of its low-quality evidence, the study became the foundation of what would become aggressive pharmaceutical marketing.

Prior to that study, opioids were almost exclusively reserved for patients suffering from terminal cancer. Purdue Pharma subsequently introduced OxyContin in 1995 and began an aggressive campaign to prove its apparent efficacy in treating non-cancer related pain. This campaign was called “Pain is the Fifth Vital Sign.”

The four vital signs are pulse rate, blood pressure, body temperature, and respiration.

Purdue Pharma funded 20,000 pain-related educational programs while also donating huge sums of money to the American Pain Society, the American Academy of Pain Medicine, the Federation of State Medical Boards, and the Joint Commission.

Additionally, Purdue Pharma lobbied doctors to view addiction as different from “physical dependence,” lambasting addiction while calling physical dependence “clinically insignificant.” In spite of this medical doublespeak, doctors responded by issuing more prescriptions for opioids. Sales of OxyContin grew from $48 million in 1996 to $1.1 billion in 2000. Doctors learned to treat physical pain with the same level of concern as they would heart irregularity or respiratory distress. The narrative of pain took hold.

White Men, Broken Expectations: When Psychological Pain Becomes Physical

Michael Kimmel  – a pre-eminent scholar of men and masculinity, is a sociologist, author, and TED speaker. He suspects that there is more to the story of the heroin epidemic and skyrocketing mortality among white Americans, and white men in particular, than the lingering economic effects of the recession.

“That sense of despair, that life will not add up to anything, that it’s all so precarious and difficult,” Kimmel wrote me in an e-mail, “Such despair is driven also by a sense of expectations, that things are supposed to be a certain way and if I do my part, then I ‘should’ get certain rewards.”

In his most recent book, Angry White Men, Kimmel captures the despair in the term aggrieved entitlement – a sense that the promises of white, male privilege never arrived. Expectations were set, only to be broken. Consider the anger of MRAs (Male Rights Activists), who deny the existence of white male privilege. Instead, they feel an emptiness, or void, and wonder why they are being called out for a privilege they don’t seem to be enjoying. They feel a sense of pain and rejection. Throughout his book, Kimmel details how men move between a numbing void and feelings of pain.

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Sociologist Clay Darcy sees this in young men who start out as recreational drug users. In his ongoing research on men in Ireland, he finds a strong correlation between constructs of masculinity and drug initiation: “These men enter into drug taking for fun, pleasure, social cohesion, to test themselves, and out of curiosity etc,” he said. “As societies become increasingly secular, there may well be a spiritual void, one that people try to fill with drugs.”

To paraphrase Hodgson, drug use provides both a sense of purpose and self-soothing skills.

From my perspective as a substance abuse counselor, this makes perfect sense. Drug dependence is total – all of your time is spent acquiring, preparing, using, and recovering from drugs. Addiction hijacks neurotransmitters responsible for goal-oriented behavior, redirecting motivation to the acquisition of drugs. The high, or relief from symptoms of withdrawal, feels more soothing than a warm embrace.

The emotional pain of violated expectations can feel unbearable. Without words to describe that sense of betrayal, the narrative of physical pain gains greater resonance. This is exactly what Brandon felt as he moved deeper into addiction. “When my doctor cut me off, I was like, ‘Now you’re doing me some kind of injustice here. And my doctor just said, ‘This isn’t real pain anymore.”

Brandon’s expectations had undergone the ultimate bait and switch: his belief in the American Dream, that he could work hard and get what he wanted, transformed into the desperate fear that he would never be free of pain.

Descent into Heroin

Brandon and his buddy were at a bar, having drinks. Aware of Brandon’s Oxy dependence, his friend slipped Brandon a small bag, under the bar, and instructed him to look at it in the bathroom. “I knew it was heroin,” Brandon said. “But I just took it and did what he said.” He snorted too much – the whole bag – thinking it would dose like Oxy. The heroin was pure, raw. That rush –  cheaper than Oxy – made the transition to heroin a no-brainer.

“As long as I did dope I never shot it,” Brandon said. “I always felt better than the people who shot it.” Insufflation is the preferred route-of-administration among middle-class users, many of whom feel that it is safer – and less stigmatized – than intravenous use. When middle-class users begin experimenting with heroin, they tend to have better financial means and can buy pure product. It’s only later, when users run low on money, that they feel forced to inject the lower-grade, cheaper product their dwindling money can acquire.

For months, Brandon had exclusive access to a trusted dealer and pure product, in part because he had financial resources: “My dealer would let me come into his house and watch him cut the heroin up, because I spent so much every time,” he said.

Over time, though, Brandon began making a series of impulsive decisions with the grossly impaired judgment of an addicted brain. “I would either ride my bike or drive my car, a 2006 Infinity G35, right into the hood. I walked around and just asked anyone I saw for heroin,” he said. “Of course they saw me, this white guy carrying around tons of cash, and targeted me.” Inevitably, he was robbed. One person beat him bloody with a gun. “I knew it was stupid. The whole time, you know it’s stupid,” Brandon said. “But you just don’t care.”

His parents were beside themselves with fear. Suspecting that something was very wrong, they confronted him numerous times. Brandon always lied about his use: “I didn’t want them to feel like they had failed,” he said.

The fear is real. From 2002 to 2013, heroin overdose deaths have increased by 286 percent. And although the Deaton and Case study highlights the startling increase in mortality among middle aged whites, data suggests that younger white Americans are following a similarly dangerous trajectory.

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I e-mailed Gabrielle Glaser, author of Her Best Kept Secret, a book about women and drinking. In the wake of her book publication, as well as the publication of her now-infamous article in Atlantic Monthly, she was contacted by countless men and women who have been failed by the substance abuse treatment system.

“The alcohol stories were hard, but what really got me were the emails from people who were struggling with opioid addiction,” she wrote. She described the repeating narrative of people who were sent to rehab; although they would achieve a brief period of abstinence, most of them relapsed, overdosing by shooting up with the same amount of heroin they had used prior to abstaining.

“Most of the patients are young men who were introduced to opioids after sports injuries, found they absolutely loved them, and quickly moved to heroin,” she wrote. “They have lost a decade of their lives spinning in and out of ineffective treatments. It’s insane. We know what works – Medication Assisted Treatments, for most people – but we don’t use it because we still somehow hang onto this idea that people have to go “cold turkey” in order to be fully recovered.

Opioid use changes the structure of the brain over time, making it so that a person cannot process normal, sensory information unless they are taking opioids. Forcing people to go “cold turkey” is the perfect setup for overdose; most of us wouldn’t be able to tolerate the way life feels with an altered brain.

Cold turkey is not a form of treatment. “Opioids are a lot more complicated than that,” Glaser continued. “They can change the chemistry of the brains so much that users don’t feel normal until they have those receptors filled.”

After his felony sentencing, Brandon followed through on methadone maintenance treatment and counseling. Over time, and under medical supervision, he discontinued methadone at a comfortable pace. He remains active in treatment and recovery groups. “A lot of guys in my groups don’t talk,” he noted. “If you’re a guy, it’s like you’re not supposed to have feelings. It’s ideal, that guys should be able to say how they feel, but I don’t know how you get there.”

Beyond the Ivory Tower 

American exceptionalism dictates that it is masculine to conquer the seemingly unconquered territories. Explorers “found” the New World. Settlers staked their hopes on the West in pursuit of Manifest Destiny. Kennedy raced against Russia to plant a flag on the moon.

Besides our pending mission to Mars, there is very little physical territory left to dominate. Where does this energy go?

Enter the Internet. In a virtual dimension, men have the ability to publish, post, and hack their way into new territory, regardless of personal politics. Men have dominated this virtual sphere and produce the majority of content. More fascinating, however, are the fringe media groups promoting male dominance, such as Rush Limbaugh (a well-known opioid addict), Matt Drudge (of the Drudge Report), 4chan, and Reddit – shining examples of the performance of masculinity. (Recall, for example, that #gamergate was all about who is entitled to perform stereotypically masculine acts.)

Next: The Role of the “Man-Box” and How it is Killing Both Men AND Women

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The post The Rising Rate of Dying White Men (and Why the Heroin Epidemic Matters to All of Us) appeared first on The Good Men Project.