A thin man with a hint of gray leans against a wall in Boston's South End and takes a long drag on his cigarette.
He thinks about a question: Why have opioid overdose mortality rates remained the same for most drug users or have they gone down in Massachusetts, but rising among blacks?
"I have no idea why blacks are higher, none at all," says Gary. We have agreed to use only first names in this story for people whose drug history could harm their chances of employment or placement.
Gary exhales, then nods. "It's the fentanyl, must be the fentanyl," says Gary.
The potent synthetic opioid, which has largely replaced heroin on the streets of Massachusetts, was present in 85 percent of overdose deaths last year.
This figure is included in a quarterly report showing that the overdose mortality rate decreased by 1
The total death toll is higher for whites, and the largest increase since 2014 is among Latinos, but the continued rise among blacks is worrying, say public health officials.
Researchers are plunging into the data in Massachusetts and across the country for a better understanding of what happens to black drug users. Data from the federal disease control and prevention centers show an increase in opioid overdose deaths among blacks in many urban areas.
The explanation is obvious to a man in Boston.
"There is an old adage when it rains. In the white community, there is a tsunami in the black community," says George, a former detainee who helps others re-enter. "That's how things are, s – rolls downhill, excuse the expression."
In the fentanyl epidemic, George says, getting blacks at the bottom of the hill is the worst cut of the drug.
People who are more prosperous will be closer to the distribution point for them to get it in their purer form, "says George." Until it comes to these communities, it has often been manipulated. These are not chemists, so these combinations often end in death. "
This is especially true for blacks when fentanyl is deliberately mixed or not with cocaine Death dates in Massachusetts show that blacks have the highest rates of death from cocaine and fentanyl Overdose has increased by 35 percent in the last three years.
Some of these deaths are likely to be people who are planning a speedball and taking cocaine as a stimulant and fentanyl as a sedative, but public health officials say many cocaine users may not realize their drugs are being laced with fentanyl.
"There was a fentanyl contamination of the cocaine supply," says Dr. Alex Walley, medical director of the opioid overdose prevention program at the Massachusetts Minister public health. "These are people who use cocaine without the intention of using an opioid … and have a much higher risk of overdose because they are opioid-naive."
Age is another risk factor for blacks. The CDC figures show the largest increases in black overdose deaths among 45- to 65-year-olds.
Some of these men and women are long-term opioid users. In Boston, Clarence, 53, says he's been heroin-addicted for 30 years and the disease has taken a toll.
"We've been beating our bodies all our lives with this addiction," says Clarence, destroying our immune system.
A weak immune system would make Clarence even more susceptible to the increased potency of fentanyl.
And there's another reason why fentanyl might overwhelm older black drug users. Ricky Bluthenthal, a professor at the Keck School of Medicine at the University of Southern California, says many of these users have committed themselves to a small maintenance dose after years of injecting and are taking just enough heroin to stay healthy.
"If the heroin people are accustomed to [it] in small amounts, and you introduce an impurity that is 50 times more potent, then that could lead to overdoses, "says Bluthenthal, who has been working as a drug analyst since 1991 risks and prevention.
Probably the deaths also relatively new drug users – a response to life with racism.
"There is increasing use among blacks as they get older," says Dr. Ayana Jordan, addiction psychiatrist at Yale University. "It can be linked to social determinants of health such as discrimination, unemployment, poverty, insecure housing – emphasizing that they develop as you get older."
Researchers explain how racism helps explain rising deaths from opioid overdose. Clarence tells another piece of the story: Imprisonment. Black men are six times more likely to be behind bars than whites, often because of stricter – and some argue discriminatory – drug-sanctioning laws. Combine this risk with this: In Massachusetts, the overdose death toll is 120 times higher for anyone who has recently been released.
"The crazy part is that we can be in prison for four or five years, get out of jail, and we want to get high that day, we do not give ourselves a chance," says Clarence.
Dr. Helena Hansen, an Assistant Professor of Psychiatry at New York University, sees things a little differently: men like Clarence do not have much of a chance.
"They are released, opioid, isolated or separated from family members with many triggers for opioid use," says Hansen. These include a lack of stable housing or income and a criminal record that makes finding a job difficult. "They buy what their previous dose of opioids was before they were arrested and they overdosed … probably at even higher rates now because of fentanyl."
If black people overdose, they probably will not call 911, says Renee, a small woman with a big smile. The topic, she says, is mistrust.
"African-American people as a whole are not cop callers," she says. "911 is the same."
Lili, a tall woman with bright red lipstick and blond cornrows, says there is no point in calling for help from a predominantly black neighborhood.
"I lived in Dorchester [where blacks are the largest racial group] and I moved to Norwood [a majority white town] .You call the police, there in a second Dorchester, you wait about 45 [minutes] an hour for a policeman who comes when they turn up, "says Lili. We feel like we are alone out here. That makes you want to take drugs sometimes.
There is concern that blacks who seek no help from police, firefighters and paramedics, will have less access to naloxone and fewer treatment pathways [In Connecticut, where the CDC says that the number of deaths is increasing] black opioid overdose has increased 135 percent between 2014 and 2016, the State Department of Mental Health is funding a 12-week recovery program in four African countries – American churches that include naloxone training and other sessions related to the opioid epidemic.
"We thought that one of the best partners would be the Black Church," says Yale's Jordan, who has organized the program. "We note that, if we are able, culturally relevant care in structures where people feel safe … people will come out. "
Jordan says the sessions have been full so far, one of the goals is to have Benu Associate with vendors who prescribe medication-based treatment (MAT). But first, Jordan and her colleagues have to convince the black people that MAT is for them. There is a history of marketing buprenorphine, for example, as a treatment especially for middle-class whites, according to NYU Hansen.
"The media and resources for drug-based treatment [are] really heavily promoted in what I call the opioid crisis aggravated by its focus on a specific user who is often a white man," says Jordan , "There is a conscious exclusion of what treatment or help looks like that keeps blacks from thinking that they can get help for this disease."
Programs such as the Connecticut Church Partnership may be most useful in urban areas with black overdose Deaths have risen most dramatically. Data provided to WBUR by the CDC show Washington, DC, at the top of the list with an increase of 213 percent between 2014 and 2016.
In Boston, the overdose deaths between 2011 and 2015 have more than doubled and rose faster than any other group. (Latino deaths increased by 142 percent and more whites have died altogether.)
Devin Larkin, who heads the Bureau of Recovery Services of the Boston Public Health Commission (BPHC) has expanded the Commission's street outreach work into the largely black communities of Roxbury and Dorchester, and has expanded its bilingual service to Spanish-speaking clients. The BPHC has also launched a home visit program that includes naloxone training and discussions with people who have recently overdosed.
"There are people who work alone behind closed doors and these are the people we really need to learn About when we want to reduce mortality in Boston because a lot of deaths happen when people are isolated and alone" says Larkin.
The figures from BPHC show that blacks among Latinos and Whites are least likely to be in a hospital after an overdose.
Massachusetts public health officials say they are in targeted interventions for blacks who are trapped in this opioid epidemic as well
"We thought this was mostly about white people for a long time," says Walley of DPH who is also a physician and researcher at the Grayken Center at the Boston Medical Center. "Now we see increases in Hispanics in 2016 and in blacks in 2016. It balances our approach, everyone is affected, we need interventions that work for everyone."
Some researchers say that they speculate on how Fentanyl's offer is hurting particular groups need not be the focus. The problem, they say, is fentanyl.
"I would step back and take a little less care of the race piece and worry more about the death sentence," says Bluthenthal of USC. "Our response to the opiate crisis, the heroin crisis, and now fentanyl poisoning has just been inadequate, so people are dying, and the problem at their base is that we did not come for the occasion."
That says Blutenthal, applies to all breeds.