A heroin epidemic is ravaging white America, as I discussed yesterday. But is it affecting more affluent Americans just as much as it’s affecting the poor and working class?

Many accounts and studies I’ve looked at, including Sam Quinones’ excellent book on the epidemic’s origins, suggest that the scale of the heroin crisis is the same across all social classes, without actually exploring educational attainment or income. The assumption seems to be that because most people abusing heroin today are white and don’t live in the inner city, they must be reasonably well off. As Quinones said, puzzling over why the heroin crisis has hit white America so hard, whites are a group “that life has generally treated pretty well, particularly in the last twenty years.”  

But according to the Centers for Disease Control, people with the following characteristics are most likely to use heroin: white race, male sex, young age (18 to 25 years), urban residence, income below $20,000, and relying on Medicaid or lacking health insurance. Among people making less than $20,000, 5.5. per 1,000 Americans use heroin. Among people making $50,000 or more, the rate is 1.6 per 1,000 people. (Both figures have risen about 60 percent over roughly the last ten years.) For people making between $20,000 and $49,999, the rate is 2.3 per 1,000 people, a 77 percent increase in roughly the last decade.

Moreover, since 2002–2004, there has been a 114 percent increase in the rate at which whites use heroin, while rates have actually gone down for people from other races and ethnicities. A 2014 study published in the medical journal JAMA Psychiatry found that almost 90 percent of people who used heroin for the first time in the last decade were white. Among recent users, 75 percent say they were introduced to heroin through prescription drugs like OxyContin. In other words, it’s mainly whites, not blacks or Latinos, who are flocking to heroin.

And it would make sense for the heroin crisis to be the most severe among poor and working-class whites. After all, as several scholars have shown, and as Quinones himself observes in his book’s portraits of Appalachian cities and small towns, working-class whites as a group have had a rough few decades. They have been at the forefront of negative U.S. trends from family fragmentation to deindustrialization. Moreover, as a Brookings report shows, more poor people now live in the suburbs than in big cities or rural towns. Just because heroin has moved into white suburbs doesn’t mean that it’s affecting middle-class and affluent Americans just as much as poor and working-class ones.

In the white, working-class neighborhood where I live, moms worry about letting their kids go to the playground because discarded heroin syringes have been found there. Last year, a team of neighbors sweeping the town for discarded syringes found one on the street in front of our house. My wife and I are also in the social circles of parents from the mostly college-educated subdivisions a few miles away, and the few parents we polled for this piece said that they kept hearing about heroin, but that they didn’t know anyone in their social networks who struggled with it, or worry that their kids might be exposed to it in their neighborhoods.  (Then again, that’s just anecdotal, and perhaps more affluent families are just more private about heroin addiction when it affects them.)

‘They live in a war zone where they’re losing their people all the time to heroin.’

Another indication about the severity of the heroin crisis among poor and working-class whites is the recent research finding that mortality rates are rising among middle-aged whites with a high school education or less, even as they continue to fall for better-educated whites, as well as for blacks and Hispanics from all educational backgrounds. Economists Anne Case and Angus Deaton concluded that the change in death rates among less-educated whites was “largely accounted for by an increasing death rate from external causes, mostly increases in drug and alcohol poisonings and in suicide.” (Drug- and alcohol-related deaths also rose among college-educated Americans, but less-educated people saw the most marked increases.) I’m left with two perplexing questions, and a comment.

First, why is it mostly whites who have succumbed to heroin? Quinones says that after spending three years doing research for his book, this is the question that still stumps him. He wonders if the heroin outbreak that devastated Latino and black neighborhoods in the 1970s left a collective scar that makes today’s Latinos and blacks averse to heroin. But he suspects there is more to the story.

Second, why do many people who legally take prescription pain medications like OxyContin never develop an addiction, while others do? It’s a question that journalist Johann Hari pursues in his book Chasing the Scream (which I wrote about here). He interviews psychologist Gabor Maté, who, based on his long work with drug addicts in Vancouver, thinks that trauma or childhood loss is the “universal template” for addiction.

But even if it’s plausible that trauma is something that many addicts have in common, it seems forced to think that all addiction is a result of trauma. What about the well-off kid from a loving family in a wonderful school who gets hooked onto OxyContin after suffering a football injury and dies of a drug overdose? Must we always unearth some hidden trauma to fit the theory?

Finally, and to Maté’s point, I can’t help but wonder if the heroin crisis might have been less catastrophic had another revolution not zeroed in on the working class: the family revolution, marked by rises in divorce and single-parent families. In making sense of how heroin and opioids have devastated Rust Belt cities like Portsmouth, Ohio, Quinones points to the economic misery that followed deindustrialization. I suspect that on top of the economic dislocation, the traumatic effects of family fragmentation and childhood loss have made the white working class especially vulnerable to heroin. A working-class friend who suffered through his parents’ divorce and childhood abuse didn’t abuse heroin, but he describes his struggle with meth addiction this way: “By the time I got to high school, I was just looking for an escape from everything that had happened. Next thing you know I’m in a basement smoking a whole bowl of meth.” Perhaps the same dynamic is in play for some people who get hooked on heroin.

Whatever the roots of the crisis, one can’t but help think of the thousands of children caught in the storm, like that seven-month-old child in his hospital room. As the physician and anti-heroin crusader Jeremy Engel told the Cincinnati Enquirer, “Heroin has created a situation where individuals whose family members are on heroin have constant exposure to trauma, drama, and layered grief. It’s a recipe for post-traumatic stress disorder.”

Engel was responding to the news that a 12-year-old girl had found her mother dead in their bathroom, a needle in her hand, just three days before Christmas. He added, “They live in a war zone where they’re losing their people all the time to heroin.”

The presidential candidates may not realize that opiate addiction hasn’t affected all of America equally, but I’m glad some of them are talking about this.