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Frontiers in Psychiatry· Erin Michelle Turner Kerrison·· 2 小时前精选AI 评分62

Frontiers in Psychiatry 文章提出法律是成瘾治疗种族差异的超级决定因素

Built to exclude: the law is a super-determinant of racial disparities in addiction treatment

AI 导读

Frontiers in Psychiatry 刊发 Erin Michelle Turner Kerrison 的文章，提出法律应被视为人群健康的超级决定因素，即法律不只是背景影响，而是通过创造资格、提供者、场所与干预四类范畴来组织成瘾治疗体系。

推荐理由

文章把法律视为成瘾治疗种族差异的构成性力量，为理解治疗缺口提供了不同于污名与供给不足的解释框架。

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摘要

美国建立了一套基于证据的物质使用治疗体系，它行之有效，但并非对所有人都有效。2024年，需要治疗的成年人中只有不到五分之一获得了任何形式的照护，包括阿片类物质使用障碍药物（MOUD），而黑人和美洲印第安人/阿拉斯加原住民社区的药物过量死亡率最高。本文认为，弥合这一差距的关键在于承认法律是人口健康的超级决定因素：它不是一种情境性影响，而是一种构成性力量，创造了治疗得以组织的各类范畴。本文借鉴构成性法律理论、种族形成理论、公共卫生批判种族实践以及行政暴力理论，展示法律如何界定谁有资格获得照护、谁可以提供照护、哪些机构被认可、哪些实践算作治疗，以及每一个范畴如何在一个世纪的种族化毒品政策中被锻造出来。本文追踪这些法律范畴在四个领域——人、提供者、场所和干预措施——中的体现，并展示它们如何汇聚，从而在社区和监禁环境中同样产生按种族分类的治疗环境。本文主张，成瘾医学必须将法律分析和批判种族方法论作为核心能力加以整合，将法律和政策改革视为治疗策略，并将法律上最受排斥的人群作为公平照护的起点。本文借鉴公共卫生和毒品政策中的废奴主义框架，坚持认为改革不应以是否在现有范畴内扩大可及性来评判，而应以是否瓦解那些首先产生种族化排斥的安排来评判。

引言：当差距本身就是重点：成瘾治疗中的种族差异

一个世纪前，国会决定某些吸毒者应得到药物治疗，而另一些则应被送进监狱。这一决定至今仍在做出。2024年全国药物使用与健康调查报告称，约4840万12岁及以上的人在过去一年符合物质使用障碍的标准（）。在5260万需要治疗的人中，只有19.3%获得了任何形式的照护，而成年人的差距在2023年至2024年间实际上有所扩大（）。在大约480万阿片类物质使用障碍患者中，只有220万人获得了阿片类物质使用障碍药物（MOUD）——这是现有最有效的干预措施（）。这一差距并非种族中立。2024年，药物过量死亡率因种族和族裔而差异显著，从亚裔美国人的每10万人4.4例到美洲印第安人和阿拉斯加原住民的51.6例；黑人美国人的死亡率为每10万人33.8例，而白人美国人为24.7例，西班牙裔美国人为17.0例（）。近期研究表明，州级无家可归率与更高的药物过量死亡率密切相关，凸显了住房不稳定作为一个结构性药物过量风险因素（）。

这场危机的种族模式有着早于当下一个多世纪的历史。黑人和拉丁裔社群因同样的物质使用行为而遭受刑事定罪，而当这些行为影响到白人群体时，却迎来了治疗创新（，）。1914年的《哈里森麻醉品法》是通过诉诸白人对中国鸦片贸易和黑人可卡因使用的种族焦虑进行游说而通过的（）。20世纪末的惩罚性升级——强制最低刑期、快克/粉末可卡因的量刑差异、大规模监禁——针对的是黑人社区，而白人的药物使用则通过医疗渠道加以管理（，）。当代阿片类药物危机的治疗导向，恰逢这场危机变得明显是白人的危机。四种“白人技术”——神经科学框架、药物设计、立法创新和定向营销——将这场危机建构为医疗问题而非犯罪问题（）。2000年的《药物成瘾治疗法》使丁丙诺啡得以在诊所环境中开具处方，该法被明确设计为美沙酮监管基础设施及其与黑人和棕色人种城市药物使用关联的替代方案（）。这段历史不是背景。它是法律类别的起源故事，治疗缺口正是通过这些法律类别被生产出来的。

成瘾医学文献长期以来记录了这一治疗缺口，将污名化、提供者意愿不足、报销不足和系统碎片化列为驱动因素，然而这些解释都有一个关键局限。它们往往回避种族。它们描述了种族化法律秩序的种种症状，却没有点明这一秩序本身——谁仍未得到治疗，服务存在于何处、不存在于何处，哪些照护模式得以维持、哪些逐渐消亡。一种具有种族意识的分析需要不同的工具。正如Devin Banks（）在其种族化物质使用污名模型中所主张的，主流的SUS学术研究通过将“种族”视为一个真实变量而非种族主义的表征，复制了这种种族回避，它依赖基于人口的调查来比较不同种族类别之间的偏见，而不是理论化反黑人种族主义如何建构污名本身。

Ford和Airhihenbuwa（）发展了公共卫生批判种族实践（PHCRP），坚持认为种族意识而非种族中立，是对健康不平等进行严谨分析的前提。Bridges、Keel和Obasogie（）将这一承诺直接延伸到健康科学领域，主张种族和种族主义对医学而言并非偶然，而是其发展的核心——因此批判种族方法对于严谨的健康科学探究而言是前提，而非装饰。Bowleg（）主张交叉性必须作为一种结构性框架发挥作用，而不是一份人口统计清单：健康差异是由种族主义、性别主义、异性恋主义、阶级主义和能力主义等相互交织的系统同时运作所塑造的，而不是由叠加的“障碍”所塑造。透过这些框架来看，治疗缺口并不是一个中立系统内覆盖不足的问题。它是这个系统如何被建造、为谁而建、以及谁的被排斥被写入其法律结构的产物。

本文主张，要理解这一秩序，并构建能够改变它的应对措施，就必须重新概念化法律的角色。具体而言，本文提出了“法律作为超级决定因素”这一理念：法律不仅仅是对健康结果产生强大影响的因素，更是一种构成性力量，它创造了治疗体系得以组织的各类范畴——谁被认定为潜在的照护接受者，谁被授权提供照护，哪些场所算作合法场所，以及哪些干预措施被资助为“治疗”。这些法律范畴从来都不是种族中立的；它们是在毒品政策的种族脚手架中锻造出来的，并持续作为种族形成的机制运作。本文借鉴法律流行病学、批判种族理论、PHCRP（，）、作为结构分析的交叉性（，，）以及行政暴力概念（），来揭示治疗不平等为何持续存在，以及 dismantling 它需要什么。黑人、非二元性别者和跨性别者、残障人士、无证和非公民移民以及老龄人口是起点——正是这些人群的经历使论点得以显现，而他们的照护正是改革必须交付的。

法律并不导致种族主义；法律将种族主义向前承载，把结构性不平等转化为具体规则，决定谁能够获得照护以及以何种条件获得。这一区分对干预至关重要。种族主义、资本主义和其他结构性力量塑造了成瘾治疗的格局——但法律是这些力量得以操作化、强制执行并对政策变得可读的机制。执业范围规则、美沙酮诊所选址要求、药房配药限制以及 Medicaid 资格条件并非凭空出现；它们将历史和持续存在的种族等级制度编码进治疗系统的架构之中。Barnett 及其同事（）发现，即使在频繁接触医疗保健的患者中，MOUD 获取方面的种族差异仍然持续存在——这证明，当管辖这些提供者能提供什么、向谁提供以及在何种条件下提供的法律结构仍然按种族排序时，靠近提供者是不够的。法律是种族主义在医学中发挥作用的地方。因此，它也是医学必须对种族主义发挥作用的地方。

关于范围的说明

本文以种族形成为组织性分析框架，因为其所考察的法律类别——覆盖范围、刑事定罪、提供者授权、干预认可——是在美国种族化毒品政策的特定历史中形成的。那段历史在其起源和运作中具有不可化约的种族主义性质，分析它需要一个足以应对这种特定性的框架。这并不削弱能力主义、跨性别恐惧症、仇外心理及其他支配体系在构建治疗差距中的独立且交叉的力量。本文在全文中将残疾（，）、跨性别排斥（）和移民身份（）作为交叉轴线加以讨论，但并未对每一者提供其应得的持续、中心化的分析。这些分析是我打算在今后工作中开展的紧迫项目。类似的边界也适用于所考察的法律层级：本分析以联邦法规为主要单位，因为Medicaid、《受控物质法》、囚犯排除条款、《心理健康平等与成瘾公平法》以及《美国残疾人法》构成了州监管、私人保险签约和地方分区运作所依托的类别。私人保险市场并非存在于这一联邦设计之外。它是由这一设计组织起来的。

理论基础：构成性法律、种族形成与行政暴力

法律作为构成性力量：从监管到类别创造

法律流行病学——将法律作为疾病成因、分布和预防因素进行科学研究的学科，通过公共卫生法律研究中心及其LawAtlas政策监测平台得以制度化——已证明，规范处方、覆盖范围和刑事定罪的法规差异与健康结果的差异相关（，）。这项工作为衡量各司法管辖区的法规差异建立了实证基础设施。但它将法律建模为作用于既有安排的独立变量——一种对健康的强大影响，而非创造医疗保健组织所依托类别的构成性力量。本文的论点建立在该基础设施之上，但与其前提分道扬镳。

法律制度主义提供了不同的前提。法律不仅仅规范那些本已存在的安排；它通过创造类别——“持照专业人员”、“被保险人”、“惩教机构”、“承保福利”——并赋予每一类别权利、义务和权力，使这些安排得以产生（）。一个人作为Medicaid受益人的身份，或一个阿片类药物治疗项目作为配药机构的身份，并非自然给定。它是一种法律产物。

Hartman（）以无与伦比的清晰度展示了这种构成性权力。在Scenes of Subjection中，她表明法律并非规训被奴役者，而是通过人格、财产和同意的范畴生产出被奴役的主体——而解放只是重组而非解决了这种暴力，延续了它表面上所取代的政权的种族逻辑。今天组织物质使用治疗的法律范畴正是源自这同一传统：它们在履行关怀的同时构成臣服，沿着自最早的联邦毒品立法以来就运作的种族界线。这一谱系并不局限于遥远的过去；关于医学实验和对美国黑人差别待遇的已有记录，确立了一部连续的医学史——医学作为种族分选的工具而非其中立的矫正者而运作（）。Bridges（）在当代福利国家中观察到了这一动态的运作，以民族志方法证明医疗补助计划的参保本身就是种族化的场所——资格认定作为一种道德分选机制，在看似管理一项中立福利的同时，治理着贫困有色人种女性的身体。

本文提出法律作为超级决定因素，作为一个区别于现有结构性解释和根本原因解释的概念框架。根本原因理论识别出跨越多种机制产生健康差异的社会条件（），法律流行病学则将法规差异作为健康结果的预测因子加以测量（），而超级决定因素框架则认为，法律不是众多决定因素之一，而是所有其他决定因素得以运作的构成性条件。这一区分并非语义上的。它对什么算作充分的干预具有直接影响。

毒品政策的种族架构

美国的毒品政策始终将白人群体的物质使用医学化，同时将有色人种社区中的相同行为犯罪化（，）。当代治疗的法律范畴——“阿片类药物治疗项目”、“2000年《毒品成瘾治疗法》（DATA）豁免”、“囚犯排除”——并非源自种族中立的起源。它们通过一个世纪的种族形成而结晶：即种族范畴通过国家行动被创造、栖居和转变的社会历史过程（）。

当法律将美沙酮限制在市中心城市的阿片类药物治疗项目中，同时允许丁丙诺啡在郊区基于诊所的实践中使用，它便构建了一种种族化的照护地理，其轮廓追踪着每种药物被设计来服务的社区——而DATA 2000的立法记录使这一设计成为国会记录中的事实，而非理论上的归因。该法案被明确审议为一条不同于美沙酮监管基础设施及其与黑人和棕色人种城市毒品使用相关联的路径（，）。范畴创造是通过法律基础设施进行的种族形成。分类系统——包括数据基础设施、风险评估和行政数据库——在看似中立和技术性的同时创造种族范畴（）。这一方法论警告直接适用于此：研究人员用来追踪各司法管辖区差异的法律数据集，本身可能编码了它们声称要测量的种族逻辑。

公共卫生批判种族实践与行政暴力

PHCRP 为这类探究提供了分析基础，它以种族意识为中心，并将分析与行动联系起来，而不是把种族差异视为偶然发现（，）。它已被应用于 MOUD 获取中的种族差异研究，表明它与本文提出的临床问题具有相关性。

PHCRP 并非作为临床工具而设计——它被设计为一种分析框架，用于在公共卫生探究中以种族意识为中心，并将分析与行动联系起来（，）。它已被用作流行病学研究中种族差异的组织性视角，并在姑息治疗中的种族不平等问题上得到实证应用（，）。该框架在此处的价值不在于作为测量工具，而在于作为一种方法论承诺——它坚持将种族视为结构性变量而非生物性变量，并坚持分析应指向消除差异，而非仅仅描述差异。应用于物质使用治疗时，PHCRP 重新调整了研究问题：不是哪些人群在现有秩序中服务不足，而是该体系的法律类别最初是如何被建构出来以产生这种服务不足的。本文所实施的正是这种重新调整。

国家对跨性别者最致命的暴力形式并非引人注目的歧视，而是例行的行政分类——福利登记表、庇护所分配、监狱住房指定——这些分类将人们归入决定其能否获得生存资源的类别。这就是行政暴力：通过那些从未被设计来容纳其所治理人群的系统的日常运作所造成的伤害（）。这一概念精确地命名了本文所描述的现象。当囚犯排除条款切断 Medicaid 覆盖，当执照标准承认基于戒断的项目却不承认减害措施，当账单代码向医生报销却不向同伴专家报销——这些都是沿着种族、性别、性取向、残疾和公民身份界线分布的行政暴力行为。这一概念还迫使本文必须面对一种张力：目标是让现有法律类别更具包容性，还是改造那些产生排斥的体系。

综合缺口

成瘾治疗文献尚未解决这一问题。Bradley 及其同事（）最近提出，将治疗设计为适应现有体系——而非颠覆它们——可能会使那些治疗声称要解决的差异永久化。基于监狱的治疗社区说明了这一点：当黑人参与者拒绝采纳对完成项目至关重要的“成瘾者”身份时，他们被解读为治疗抵抗，而不是被视为该模式从未为他们而建的证据（）。Kaba（）直言不讳：这个体系没有坏；它正按设计运作。如果法律基础设施按设计产生种族化排斥，那么临床医生和研究人员所称的治疗失败就是一个用词不当。

这种重新框定并不否定现有针对成瘾治疗缺口的研究路径。结构性决定因素研究已经记录了哪些因素与差异化的结果相关；法律流行病学已经量化了具体法规如何预测护理可及性的变化（）；卫生服务研究已经描绘了治疗能够到达——或未能到达——需要治疗的人群的组织和关系条件（，）。这些路径都没有做的是将法律理论化为构成性的而非背景性的——即法律是创造成瘾治疗系统赖以组织的人、提供者、场所和干预类别的力量。

一个合理的反对意见是，成瘾医学和公共卫生已经认识到健康的结构性和社会性决定因素（SDOH）。但将法律视为一种决定因素仍然使它像天气一样，是临床医生和组织必须应对的东西。这里的论点是，法律是地质——它创造了社会决定因素框架视为既定的组织、角色和合格人群，并决定了所有这些应对行为所发生的地形的轮廓。标准的SDOH框架将决定因素分为五个领域：经济稳定性、教育机会和质量、医疗保健可及性和质量、社区和建成环境，以及社会和社区背景（）。法律在这份清单中没有作为第六个领域的位置。法律界定了清单上每个领域的边界，决定谁有资格被视为经济足够稳定从而失去援助，犯罪记录是否妨碍获得住房或社区领域，医疗保健可及性在法律上是否根本可用。超级决定因素的主张是，法律先于结构性决定因素，而非与之平行。追问法律对成瘾治疗系统做了什么，意味着对每个领域追问：法律分类如何建构了那些使治疗缺口不是偶然的而是被设计出来的类别。

法律塑造临床结果这一论点对医学来说并不陌生——它正日益成为医学的核心。Barnett及其同事（）在《New England Journal of Medicine》上发表了MOUD获取中的种族差异，发现尽管频繁接触医疗保健，差距仍然存在——这一发现指向法律结构而非临床实践是主要驱动因素。最近《JAMA》一篇关于MOUD的综述指出，联邦法规将美沙酮限制为仅限诊所配发，是治疗可及性的一个决定因素——一个嵌入临床综述中的法律约束（）。《The Lancet》将毒品从禁止转向监管视为公共卫生的当务之急（40）。本文提出的问题——法律是治疗缺口的构成性因素而非偶然因素——正是医学已经在追问的问题。下面我将探讨这个问题。

法律是健康投入与产出的超级决定因素——并非因为它是众多影响因素中影响最大的一个，而是因为它构成了所有其他影响得以运作的场域。污名影响医疗服务提供者是否开具丁丙诺啡——但法律决定该提供者是否被授权开具。组织文化影响监狱是否提供治疗——但法律决定医疗补助是否会为其付费。提供者的不情愿影响谁被转介至减害服务——但法律决定减害在该司法管辖区是否为合法活动。在每一种情况下，非法律因素可以在法律允许的空间内推动指针。它无法移动边界。这正是法律具有构成性而非背景性的原因，也正是“超级决定因素”的含义：不是回归中最强大的变量，而是设定所有其他变量可变范围的变量。

法律作为超级决定因素：类别创造作为种族形成

如果法律是构成性的而非背景性的，如果其类别与种族形成不可分割，那么问题就变得具体：法律分类究竟如何组织物质使用治疗系统，又沿着哪些界线进行分类？答案横跨四个领域——人、提供者、环境和干预措施——而在每一个领域中，治疗缺口都是分类本身的下游产物。

人：资格、排斥与可弃性的法律建构

临床和公共卫生研究通常将可能接受治疗的人群视为既定，然后衡量谁被覆盖到。在物质使用治疗中，该人群的边界深受带有种族内容的法律规则塑造。

医疗补助扩展状况最直接地说明了这一点。在扩展州，低收入成年人原则上可以获得覆盖的治疗。截至2026年初尚未扩展医疗补助的十个州中，具有相同需求和收入的人在法律上处于该覆盖类别之外（41）。这不是随机分布。覆盖缺口中的140万人中，近四分之三生活在三个南方州——德克萨斯、佛罗里达和佐治亚——而97%生活在南方（41）。非扩展州的黑人和拉丁裔居民比例不成比例地更高，非扩展州的未保险率几乎是扩展州的两倍（42）。医疗补助扩展在历史上被红线划定的普查区中最大幅度地减少了无保险状况，这表明扩展与非扩展之间的法律边界与早期种族排斥形式沿着相同的地理界线运作（42）。“覆盖缺口”不是抽象的政策产物。它是法律建构的种族地理——资格作为一种道德分类机制运作，管理着贫穷有色人种女性的身体，却看似在实施一项中立的福利（）。

移民法制造了种族排斥的第二道边界。《个人责任与工作机会协调法案》及随后的医疗补助法规将大多数无证移民和许多新近合法移民排除在全面医疗补助之外，使他们无论临床需要如何，都只能获得仅限急诊的照护（43，44）。那些身处此地却对国家照护体系不可见的人，构成了一个由法律生产出来的人群——对这些人而言，物质使用治疗体系根本不存在。这并非偶然的排斥。移民身份是一种法律建构，它制造出在类别上完全处于任何以保险覆盖为前提的治疗体系触及范围之外的人群（）。

刑事法律身份增添了第三层。医疗补助的被监禁者排除条款（42 U.S.C. § 1396d(a)(A)）禁止为被监禁者提供的服务提供联邦匹配资金，将他们从社区健康体系转入惩教健康体制，而后者承担着不同的——且通常更为低劣的——义务与选择。鉴于黑人男性的监禁率约为白人男性的五倍，被监禁者排除条款实际上发挥着一种带有种族模式的覆盖排斥作用（45）。在监狱和看守所中，黑人和拉丁裔人相比被监禁的白人，在羁押期间接受任何物质使用障碍治疗的可能性也显著更低，且更可能被安排到惩罚性而非治疗性的项目中（46，47）——被监禁者排除条款切断了本可为治疗性替代方案提供资金的覆盖，从而加剧了这种种族分选（）。获释之后，人们必须在用药过量风险急剧升高的时期应对重新参保，而定罪带来的附带后果——住房禁令、就业排斥、监管条件——进一步限制了谁能进入治疗并留在治疗中（48）。

第四类是通过联邦印第安法构成的。美国对部落民族负有基于条约的信托责任，须为其提供医疗保健，主要通过印第安人健康服务局（IHS）履行。然而这一义务是通过自由裁量的拨款来兑现的，致使IHS相对于需求长期资金不足，产生出一种作为独特法律类别存在、却被系统性地剥夺资源的治疗基础设施（49）。与其说是覆盖上的缺口，不如说这是一种通过法律设计按更低标准建造的覆盖结构。其后果在本文所聚焦的领域尤为严峻：AI/AN社区面临着全国最高的用药过量死亡率之一，而MOUD恰恰在信托义务本应保障其可及的地方最为匮乏（50）。因此，联邦类别“有资格获得IHS照护”与其说是一种保障，不如说是一种圈禁：它命名了一个国家有义务服务的人群，同时又将这种服务结构性地设计为失败。

这些规则并非仅仅影响一个固定人群内部的获取机会。它们相对于治疗体系创造出不同的法律类别：持续参保且作为受益人可见的人、间歇性连接的人，以及结构性地处于体系之外的人。

另外两个排斥轴线加剧了这种分类。跨性别和性别不合规者面临的分类系统在入院时强制进行二元性别指定，拒绝其获得适合其性别的住院治疗，并在庇护所和减害环境中对他们进行歧视性执法——这正是Spade（）所描述的行政暴力。即使是表面上包容跨性别者的监禁改革，也作为新的性别控制模式而非救济手段运作，因为分类机制本身就在实施伤害（51）。种族与性取向的交汇构成了第二个轴线。阻碍男男性行为黑人获得HIV检测和预防服务的结构性障碍——涵盖医疗可及性、污名、监禁和贫困——包括惩教设施中已记录在案的服务不足，尽管该人群的监禁率不成比例地高（52）。

残障人士面临类似的抹除——他们缺席于治疗证据基础并非偶然，而是一个从更容易招募的人群开始的领域的结构性特征。危险性和犯罪性是种族主义和能力主义建构，被嫁接到残障和“精神疾病”之上——刑事法律系统在制造残障的同时，将残障作为拘禁的理由（，53）。例如，Ben-Moshe（）表明，去机构化和大规模监禁并非分离的轨迹，而是监禁重组的相互关联过程——是拘禁的重新分配，而非解放。物质使用障碍横跨医疗化和刑事化，而谁进入哪条轨道的法律分类同时映射到种族和残障身份上。Morgan（54）关于种族与残障作为美国法律共同建构的谱系学表明，能力主义修辞从动产奴隶制时代起就被纳入黑人的法律定义中——将黑人同时建构为体力上能够从事残酷劳动而智力上低劣，随后又将其建构为病态犯罪者——这表明组织当代治疗轨道的医疗化/刑事化二元对立深深植根于法律生产的种族-能力主义秩序中。

老龄化以成瘾治疗领域系统尚未正视的方式加剧了这些排斥。患有物质使用障碍的老年人是治疗需求人群中增长最快的部分——2021年和2022年全国药物使用与健康调查的汇总数据发现，710万60岁及以上成年人在过去一年中患有物质使用障碍，850万人被归类为需要物质使用治疗，但需要治疗的人中不到三分之一接受了任何治疗（55）——然而几乎没有任何项目——无论是社区还是监禁场所——是针对他们的临床特征设计的，这些特征通常涉及多种物质使用以及慢性病管理、认知变化、多重用药和功能限制。管辖治疗的法律类别是围绕更年轻的原型建立的：联邦政策想象中的“成瘾者”处于工作年龄、身体强壮，要么可被监禁，要么可被雇佣。在数十年物质使用后原地老龄化的老年人，或从漫长的监禁刑期中老龄化出来、进入一个假定身体能力和劳动力市场准备的重新融入基础设施的老年人，占据了系统所承认的类别之间的空白。

年龄与种族、性别及监禁史的交织对黑人女性尤为严峻，她们既承受着“风化”带来的累积健康代价（56，57），又面临着被压缩的回归社会时间窗口——在这段时间里，时间的流逝使改造项目所要求的身份转变成为不可能（58）。对于仍在监禁中的更年期黑人女性，伤害更为深远：监狱基础设施的设计未考虑她们的生理特征，处方集排除条款实际上等同于对激素治疗的禁令，症状被错误归类，将生理事件转入纪律惩戒渠道——包括单独监禁——这一连串法律和行政分类的失败，其后果可预见、可预防，达到了宪法上“故意漠视”的门槛（59）。Medicare资格、社会保障残疾认定以及基于年龄的服务门槛引入了额外的法律分类，这些分类可能与针对物质使用障碍（SUD）的特定类别相冲突或重复，造成行政上的纠缠，对于太疲惫——或太病重——而无法应对的人来说，这实际上构成了排斥。

服务提供者：授权角色与治疗权威的种族分布

法律不仅决定谁获得照护，还决定谁被授权提供照护，以及以何种条件提供。在物质使用治疗中，谁算作合法提供者是一个法律判定，而这个判定是按种族秩序排列的。

美沙酮/丁丙诺啡的分野是最清晰的例证。根据《受控物质法》及其实施条例，用于阿片类药物使用障碍的美沙酮仅限于阿片类药物治疗项目（OTPs）——这些机构要求每日或近乎每日到场，集中在城市地区，受到广泛的监管，且长期以来与黑人和棕色人种社区相关联。丁丙诺啡通过DATA 2000在办公室环境中得以使用，其明确设计初衷就是作为美沙酮种族化基础设施的替代方案（，）。关于谁能开什么药、在哪里开药的法律框架并非偶然地种族化；它是通过种族逻辑构建起来的。例如，被诊断患有阿片类药物使用障碍的黑人患者，通过OTPs获得美沙酮的可能性显著高于通过办公室实践获得丁丙诺啡，而白人患者则呈现相反的模式（60，61）。这种分布与每种药物可配发地点的法律地理相吻合。一条路径将人们引入需要每日到场的严格监管诊所。另一条路径则在医生办公室提供私密、灵活的治疗。这两条路径之间的法律边界也是一条种族边界。

除药物之外，执照和计费规则决定了谁的劳动能被报销体系看见。医生和某些持照临床医生占据着作为独立计费者的法律赋权地位。社区卫生工作者和同伴康复专家——他们往往特别擅长接触被正式系统边缘化的人群——在各州未被承认或承认程度不一致（62）。在他们的工作无法计费的地方，他们的角色始终是临时性的（63）。其结果是一种提供者等级体系，其中关系性权威（谁能真正接触到人）与法律权威（谁的服务能被报销）彼此错位，而这种错位映射着种族与阶级。

对“循证治疗”的法律承认，优待的是在 predominantly white 样本中得到验证的临床模式，而减害、互助和植根于文化的实践则仍处于资本主义报销体系所奖励的类别之外。这种等级体系反映的是法律类别本身的种族架构，而非这些方法相对的有效性（64）。黑人、拉丁裔和原住民减害实践者——其基于社区的模型明显比标准化临床方法更有效地服务于边缘化人群——被结构性地排除在报销体系所承认的提供者等级体系之外（65）。

场所：作为种族化法律类别的设施

物质使用治疗发生在这样的场所中：其存在、位置和允许的活动由法律决定。这些决定是种族化的。

分区和选址决策塑造了治疗能够在物理上存在于何处。邻里对 OTP 和住宿式设施的反对，常常通过分区挑战、有条件使用许可或妨害索赔来表达，这些手段限制容量或将设施从需求最高的地区驱逐出去——这些分区限制本身就被描述为将空间种族化的策略（66）。治疗荒漠不是景观的自然特征。它们是由关于设施可以在何处运营的法律决定所生产出来的。

监禁场所构成一个平行的治疗环境，受一套完全不同的法律制度管辖。上述覆盖排除在结构上将监禁医疗与社区系统分隔开来。没有统一的联邦强制规定要求监禁设施提供全方位的循证SUD治疗（67）。尽管Estelle v. Gamble案（1976年）确立了宪法底线，这一缺口依然存在——该案仅要求避免对严重医疗需求的故意漠视，而非要求护理达到社区临床标准。在社区环境中，MOUD代表临床标准——然而如上文所述，约480万阿片类药物使用障碍患者中仅有220万人实际获得该治疗，这一缺口正是本文所追溯的法律类别交互作用所产生的。在监狱高墙之内，同样的药物面临截然不同的障碍：它们被视为例外或具有风险，并非因为临床证据不同，而是因为管辖的法律类别不同（68）。囚犯排除条款、受控物质法规以及缺乏具有约束力的护理标准，共同构建了一个环境，在其中社区侧的获取问题不仅被复制，而且在法律上被叠加放大。来自监狱治疗提供研究的实证证据证实了这种叠加效应：即使监狱内部存在治疗基础设施，决定谁获得护理的是组织和法律因素——而非临床因素（69）。

减害环境处于最不稳定的法律地位。针具服务项目、监督消费场所和低门槛临时服务中心存在于法律灰色地带，或在许多司法管辖区被明确禁止（64，70，71）。这种法律边缘性并非其“在人们所在之处与之相遇”使命的附带现象。它反映了一个事实：它们所服务的人群——正在使用药物的人、无家可归者、无证移民、反复进出监禁系统的人——本身在法律上就处于不稳定状态。在减害属违法的地方，无论需求如何，它根本不会出现在正式的治疗规划中。

干预措施：将治疗在法律上认定为种族分类

最后，法律以沿种族化轨道引导资源的方式界定哪些实践算作“治疗”。

Netherland和Hansen（）记录了医疗化轨道如何为白人阿片类药物使用者构建，而惩罚性轨道如何为有色人种社区构建。这种双轨制通过法律得以维持。事先授权规则、阶梯治疗要求、咨询强制规定和尿液药物筛查要求，实际上将治疗重新定义为以戒断为条件，即使证据支持在持续物质使用的同时继续用药（72–74）。这些要求构成对《心理健康平等与成瘾公平法》的系统性违反——该法禁止对SUD福利施加更严格的治疗限制——以及对《美国残疾人法》的违反——该法禁止在联邦资助环境中拒绝提供MOUD（75）。

关于监狱内治疗社区的研究已经表明，这些动态如何在生活经验的层面上运作。在一项针对300名至少完成了12个月监狱内治疗社区项目的刑满释放人员的研究中，白人参与者更有可能最终接受“成瘾者”这一标签，并谈论由此获得的特权和重新融入社会的支持（）。黑人参与者则更有可能抗拒这套治疗话语——要么未能完成项目，要么进行一种基于缺陷的自我叙事，而不投入其内容。同一项干预措施产生了种族差异化的结果，原因并非动机上的个体差异，而是其运作所处的种族化法律与社会类别，使“成瘾者”这一标签对某些人成为保护性身份，对另一些人则成为叠加的污名。正如一位黑人参与者所说，该项目“从来就不是为了帮助黑人而设计的”（）。

这些治疗模式的历史谱系本身就是种族化的：从20世纪30年代的联邦麻醉品农场，到匿名戒毒会，到治疗社区，再到当代的药物辅助治疗，每一种相继出现的模式都更好地服务于白人参与者，而使有色人种参与者对康复的准备更为不足（76）。尽管上述文献记录了该模式的种族主义局限，监狱内治疗社区仍然是高墙之内被最广泛采用的物质使用障碍治疗模式之一。

减害在法律上的不稳定处境——上文已将其详述为一种环境层面的排斥——同样作为一种干预层面的排斥而运作。不属于“治疗”这一法律类别的服务无法利用标准的资金来源，无论其证据基础如何。组织会理性地回应这一激励结构，建立并维持法律基础设施所奖励的模式——这些模式在历史上是为白人群体设计并以其为验证对象的。

地图即机制：法律类别与种族排序

在这四个领域中，法律绘制了物质使用治疗系统的基本地图——界定哪些人在结构上可见、哪些专业人员掌握着照护的钥匙、哪些场所可以容纳服务，以及哪些做法被命名为治疗并获得资助。这张地图是按种族排序的。它的轮廓勾勒出一个历经一个多世纪刻意排斥而组装起来的毒品政策机器（77）。

由此对成瘾医学和临床实践产生两点启示。第一，许多熟悉的障碍——“治疗荒漠”、缺乏处方者、脆弱的低门槛模式、围绕监禁与重返社会的缺口——是法律类别创设的下游产物，而非纯粹的组织缺陷。解决它们意味着改变这些类别，而不仅仅是在类别之内调整策略。第二，将法律视为超级决定因素，可以厘清哪些问题能够通过临床和组织努力切实得到解决，哪些则反映了硬性的法律约束。在法律类别较为宽松但未被充分利用的地方，这类工作或许能够弥合缺口。这一区分对研究和实践都很重要。

在控制临床接触后，MOUD 获取方面种族差异的持续存在，是现有最强有力的证据，表明提供者和患者因素虽然真实存在，却不足以解释这一现象。Guerrero 等人（78）记录了一种二元化的阿片类药物治疗体系：丁丙诺啡通过诊所式执业流向白人、有私人保险的患者，而美沙酮则通过高度监管的诊所输送给黑人和拉丁裔患者——这种分布遵循的是每种药物可在何处配发的法律地理，而非个体提供者的偏好或不愿。Miles 等人（79）报告称，2015 年至 2019 年间，尽管提供者队伍显著扩张，Medicare 受益人中丁丙诺啡获取的种族差异仍持续居高不下。Schuler 等人（80）发现，广泛的豁免政策——联邦扩大丁丙诺啡处方者队伍的主要策略——不足以弥合分配中的种族差距。Moon 及其同事（81）表明，种族和经济隔离可预测药房层面丁丙诺啡配发的受限，且独立于处方者的可及性。这些研究呈现的模式是一致的：赋能提供者的政策在现有法律结构内扩大了可及性，却未纠正那些在患者尚未接触到提供者之前就按种族线将其分类的结构性条件。污名是真实的。提供者的不情愿是真实的。但它们运作于一个法律场域之内，而这个场域的边界决定了谁首先到达临床接触——以及以何种条件到达。

社区与监禁环境：法律类别交汇之处

没有任何单一法律类别能独自造成治疗缺口。缺口出现在类别交汇之处——覆盖排除、提供者稀缺、设施缺失和干预限制在同一地点叠加于同一人群。两种治疗环境使这种交汇变得可见：社区治疗和监禁环境。二者之间的边界本身就是一种带有种族内容的法律建构。

社区治疗：谁出现，谁不可见

设想一个人，患有阿片使用障碍，生活在未扩大 Medicaid 的州，最近从监狱释放，没有合法移民身份。三种法律类别同时交汇于此人身上：Medicaid 未扩大按收入将其排除，囚犯排除条款已切断其先前任何覆盖，而移民法无论如何都禁止其获得全面 Medicaid。没有任何单一障碍能解释其被排除在治疗之外。是交汇造成的。每个类别单独都缩小了可及照护的人群；合在一起，它们建构出一个社区治疗系统在功能上并不存在的人群——这是数百万人面临的复合现实，他们的法律身份交汇于系统从未设计覆盖的接缝处（，82）。

即使对于拥有稳定保险覆盖的人群，类别之间的相互作用也制约着治疗的实际形态。扩大医疗补助州的一名医疗补助受益人在原则上可能有资格获得MOUD，但如果其所在县没有阿片类药物治疗项目——因为分区方面的挑战阻止了唯一拟议的选址——而该地区为数不多的初级保健临床医生又拒绝开具丁丙诺啡，那么“符合资格的人”“获授权的提供者”和“被认可的环境”这些类别就无法对齐。有保险覆盖却没有在可计费机构中的就近处方者，这是一种没有实质体现的法律权利。由此产生的“治疗荒漠”并非单一原因造成的问题；它出现在保险覆盖规则、受管制物质法规、执业范围法律和地方土地使用决策的交汇处。在农村背景下，这些汇聚的法律约束与本身就能预测过量用药风险的警务模式相互叠加，从而产生这样一种情形：在组织策略能够运作之前，治疗的条件在法律上就已被封闭（83）。

对什么算作治疗的定义引入了又一层筛选。当以戒断为导向的住院项目比整合式的、基于药物的门诊治疗更容易满足许可标准和付款方合同要求时，组织就会建设法律激励结构所奖励的东西。一个寻求低门槛、以减少伤害为导向的MOUD的人可能会发现，其所在地区唯一可报销的选择是一个强制戒断的住院项目——这种错配并非源于个人偏好，而是源于法律如何构建可用的选择。对于已经在交叉性劣势中挣扎的人群——面对二元入院分类的跨性别者（84）、害怕在登记时出示身份证明的无证移民、需求落在为更年轻群体设计的项目之外的老年人——其复合效应不仅仅是可及性降低，而是被该系统主动排斥。

社区治疗并不是一个具有统一覆盖范围的单一实体。它是重叠法律管辖区的拼凑物，会根据某个人所处的类别产生截然不同的治疗条件。为保险充足、居住稳定的患者建立的临床方法对那个人可能是有效的。它们无法触及生活在类别之间缝隙中的人——而这些缝隙正是种族排斥按设计累积并叠加的地方。

监禁环境：排斥的法律生产

社区/监禁的边界并不是一条中立的管辖线。它是一个法律开关，会一次性翻转多个类别。当一个人进入看守所或监狱时，医疗补助的被监禁者排除条款会切断其保险覆盖。受管制物质法规使那些在社区中曾是标准治疗的相同药物难以或不可能继续使用。设施的许可和合同框架决定是否提供任何SUD治疗。而这个人的法律身份从患者——无论多么脆弱——转变为被监禁者，这一类别受宪法最低标准而非临床最佳实践治理（85）。这些类别转变同时发生，而它们的相互作用正是产生监禁治疗环境的原因。

James（86）坚持认为，国家暴力并非作为反常现象运作，而是作为结构性常态——它在种族与性别的交汇处被组织起来，通过制度化的日常运作得以维系，并被那些声称反对它的框架本身变得不可见。监狱式的治疗环境正是这一洞见的体现。暴力不仅在于药物的缺失；它在于一种法律制度，该制度将被监禁者定义为类别上不同的主体，对他们而言，允许适用更低标准的照护——这些主体的治疗，即便存在，也要经过凌驾于临床判断之上的安全逻辑的过滤。国家将自己同时定位为伤害的来源和救济的裁决者，以加深其所声称服务之人所受支配的条件提供“康复”。

干预类别与监狱环境之间的相互作用产生了其自身的种族化动态。正如我上文所论证的，监狱环境中可用的干预类别绝大多数是为白人男性原型而建立的戒断导向治疗社区。表面上的个体治疗失败，在结构层面上，是将羁押环境施加于它从未被设计来服务的人群所产生的可预测结果。

作为法律断裂的过渡

重返社会并非照护中的“缺口”。它是一次法律断裂。保险覆盖终止或失效。重新登记需要文件、预约和行政处理，而这一切都发生在极度脆弱的时期——刚获释的人在释放后的头两周内，其过量死亡相对风险是普通人群的129倍（87），这一发现在八个国家的140万人中得到了重复验证（88）。住房法规、公共援助资格规则和监督条件决定了个体能否稳定下来。一个离开监狱的人可能会发现，支配其身份的法律类别——因保险覆盖失效而无保险，因定罪而无资格获得某些住房，因治疗系统声称要解决的同一种物质使用而受到儿童福利审查——使得持续治疗变得困难，即便社区项目存在并愿意参与。

近期的政策动向——将在后文影响部分更充分地讨论——表明这一问题已得到部分认识。美国医疗保险和医疗补助服务中心于2023年发布指南，允许各州申请第1115条豁免，覆盖释放前最长90天的服务，截至2025年中期，已有十一个州获得批准（41，89）。2025年《重返社会法案》在跨党派支持下提出，将允许各州在释放前最多30天恢复医疗补助（90）。这些是有意义的步骤，一个合理的反对意见是，它们表明该体系具有自我纠错的能力——证明法律类别并不像分析所暗示的那样固定不变。但这些改革证实而非削弱了这一论点。X豁免被2023年《综合拨款法案》取消（91，92）。重返社会覆盖需要新的豁免授权。减少伤害授权需要肯定性立法。在每一种情况下，约束性限制都是法律类别本身，而消除这一限制——而非仅靠组织改善——才是扩大可及性的必要条件。这些改革表明，当治疗差距缩小时，它之所以缩小，是因为有人改变了法律，而不是因为有人在旧规则内运行了更好的培训项目。在监禁环境中，诉讼一直是这种变革的机制之一。在Pesce诉Coppinger案（2018年）和Smith诉Aroostook县案（2019年）中，联邦法院裁定，拒绝向被监禁者提供MOUD违反了《美国残疾人法案》（ADA）——该法案将物质使用障碍列为合格残疾——以及第八修正案。这些案件正在确立一种不断演变的医疗法律先例，将法律类别的消除，而非组织的意愿，命名为获得治疗的必要条件（75）。成瘾医学有义务遵循法院所引领的方向。

那么，这一边界并非自然形成的。它是一种法律建构——由医疗补助囚犯排除条款、监禁护理缺乏约束性标准、对相同药物因环境不同而区别对待的受控物质法规，以及在风险最大的时刻切断连续性的资格规则所维持。正如本文考察的其他法律类别一样，它也是种族化的。承受这一法律断裂全部重负的人群，正是被Lisa Marie Cacho（93）称为“社会性死亡”的人——通过刑事定罪、移民执法和福利排斥等相互交织的制度被剥夺了可识别的人格，其中黑人、拉丁裔和原住民比例过高。从这个意义上说，社区/监禁的二分法是一种种族分类技术——医学和公共卫生很少如此命名它。

法律素养使什么成为可能

本节提出对成瘾医学和卫生政策的四点启示。我建议将治疗失败重新定义为法律设计，将法律分析和批判种族方法论整合到临床和研究实践中，扩大策略库以纳入法律和政策变革，并将受影响最严重的人群作为起点。

The recommendations that follow are not positions in advance of evidence — they are conclusions the evidence has already reached. On decriminalization, studies of Oregon’s Measure 110 — passed through community-organized ballot initiative — found no association between drug possession decriminalization and increased overdose mortality (94–97). Malinowska-Sempruch and Lohman (40) characterized the shift from prohibition to regulation as a public health imperative supported by population-level evidence. On supervised consumption: Milloy et al. (98) documented overdose deaths averted by Vancouver’s supervised injection facility, and Zhu et al. (99) synthesized lessons for North American implementation. On peer specialist reimbursement: Bell et al. (100) conducted a scoping review of peer workforce outcomes, and Gibbons et al. (101) found that peer support was associated with increased buprenorphine receipt and a 0.4 percentage-point reduction in overdose risk among Kentucky Medicaid enrollees. On Medicaid continuity at reentry: Andraka-Christou and colleagues (102) found expert consensus that automatic Medicaid re-enrollment for returning citizens is among the highest-value, most implementable policies available. Each recommendation has a peer-reviewed evidentiary basis. The question is not whether the evidence exists — it is whether medicine is prepared to follow it.

Reframing failure as design

Much of what medicine calls a ‘barrier’ in substance use treatment is a boundary, simply a line law drew, determining what the system is and who it is for. The absence of MOUD in a rural county is not primarily a function of provider reluctance when the county has no opioid treatment program and no buprenorphine prescriber—conditions determined by licensing, scope-of-practice, and controlled-substance regulations (100, 101). The discontinuity of care at reentry is not primarily an enrollment failure when the Medicaid inmate exclusion has severed coverage by design. The marginality of harm reduction services is not a function of weak organizational capacity when those services are prohibited by state law or excluded from benefit packages.

A race-conscious reframing goes further. It asks not just “what legal rule created this barrier?” but “for whom was this barrier created, and whose exclusion does it produce?” When the legal platform was built through a century of racialized drug policy (, ), the racially patterned gap is not an unintended consequence of otherwise neutral rules. It is the foreseeable output of a system whose categories were designed to sort along racial lines.

To be clear, the argument is not that stigma, provider reluctance, and organizational constraints are imagined. They are well-documented and consequential. But they operate within a legally constituted field whose boundaries determine their scope and distribution. Stigma against people who use drugs exists everywhere, but it yields different clinical outcomes in a state that has expanded Medicaid and authorized harm reduction than in one that has not. My principal questions interrogate what structures the conditions under which stigma translates into denial of care—and that structuring is legal. This distinction matters practically. It separates problems addressable by training, technical assistance, and organizational development from problems that rest on hard legal constraints. The legal constraint is not the context for the clinical problem. It is the clinical problem.

Cultural competency training cannot restore Medicaid to someone the inmate exclusion has rendered uninsured. Learning collaboratives cannot create an OTP where zoning law prohibits one. Provider education cannot make harm reduction billable where state law defines it as outside the category of treatment.

Legal analysis is a clinical competency

The call to expand medicine’s analytic repertoire is not new. Metzl and Hansen’s framework of structural competency urged clinicians to recognize how forces above the individual clinical encounter — policies, economies, and legal regimes — shape health outcomes, and to develop an extra-clinical language for naming them (103). Metzl and Roberts (104) extended this specifically to racism, arguing that structural competency remains incomplete unless it reckons with how medical categories themselves encode racial hierarchy. Legal analysis as a clinical competency builds directly on that call — and names law as the specific structure through which racialized exclusion is operationalized. Emergency physician, Uché Blackstock, has documented how policy rather than biology manufactures racial health inequity, and has called on medicine to treat that fact as a matter of professional responsibility rather than external politics (105). Legal analysis is one form that responsibility takes.

That diagnosis calls for two methodological integrations. First, legal analysis must become a core competency of clinical and public health research, not a peripheral specialty. Systematic mapping of laws across jurisdictions — developed by legal epidemiology () — should be combined with PHCRP’s race-conscious orientation (, , ). Standard legal mapping documents what laws exist. A race-conscious approach goes further: it asks for whom those laws were built, who they exclude, how exclusion is racialized, and how legal categories interact to produce compounded exclusion for populations at the intersection of multiple marginalized statuses. Extending it to the full range of legal categories this article has identified — coverage, immigration status, criminal legal status, provider authorization, facility licensing, intervention recognition — would produce a far more granular account of how law structures the treatment gap along racial lines.

Second, intersectional analysis must function as a structural framework in clinical and public health research, not as a demographic variable added to regression models (, , ). Studies that examine race, gender, disability, citizenship, and age as separate predictors will miss the compounded exclusion that legal categories produce. The Medicaid inmate exclusion does not operate identically for a Black trans woman with a disability and a white cisgender man; the legal categories converge differently, and the administrative violence () is experienced differently because blackness and transness are historically co-constituted rather than separable axes (106). This is why the communities navigating these legal categories must be partners in how those categories are defined and measured, not simply subjects of the analysis.

Policy change is a treatment strategy

The clinical and public health response to the addiction treatment gap has relied heavily on organizational and individual strategies: training, facilitation, audit and feedback, coalition-building, financial incentives. These are necessary but insufficient when the binding constraint is legal rather than organizational. If law is a super-determinant, then legal and policy change must be recognized as core treatment strategies, not distant contextual influences. This reframing echoes prior calls to put social and policy interventions into clinical practice — including harm-reduction programming in the face of punitive drug laws — as legitimate clinical, not merely advocacy, activity (107).

Scope-of-practice rules should be revised to reimburse peer specialists and community health workers. Licensing and zoning standards should permit integrated, medication-based, harm-reduction models where need is greatest. Medicaid and correctional policy should ensure continuity of coverage through incarceration and reentry. The inmate exclusion should be eliminated. Drug possession should be decriminalized. Harm reduction services — including supervised consumption sites — should be authorized. Each of these addresses a legal category that currently constrains what clinical practice can achieve, and each belongs in the same conversation as prescribing decisions and dosing protocols.

Spade () challenges this framing with a question that the article must engage honestly: when the administrative systems themselves are the source of harm, is inclusion sufficient? Easing buprenorphine prescribing rules does not change the fundamental regulatory structure that confines methadone to opioid treatment programs. Expanding Medicaid pre-release coverage does not transform the carceral system that produced the coverage rupture. Kaba () Davis (108), and Gossett et al. (109) press the point further. Does expanding treatment within carceral settings legitimize those settings? The abolitionist challenge does not invalidate legal reform, but it insists that reform be evaluated against a different standard—not whether it makes the existing system more inclusive, but whether it moves toward a system world in which the legal categories that produce racialized exclusion are no longer operative. This distinction is one addiction medicine is only beginning to reckon with.

Centering the most affected populations as starting point

Hooks (110) argued that marginalized communities occupy a position of epistemic privilege — a vantage point from which the operations of power are visible in ways they are not from the center. Ford and Airhihenbuwa (, ) operationalized this commitment within PHCRP as “centering in the margins”: beginning analysis from those most affected rather than treating them as a subgroup examined after general findings have been established. This commitment has direct implications for how addiction medicine and public health design studies, select strategies, and evaluate outcomes in substance use treatment.

As discussed in Section III, populations that use substances while occupying the intersection of multiple marginalized statuses — Black men who have sex with men navigating both HIV and incarceration, for instance (52) — remain virtually absent from the treatment evidence base. The field excludes the people most affected by interlocking systems. This is not an oversight. It is a structural feature of a research enterprise that begins from the “general population” and then asks why certain subgroups are underserved. Research that begins instead from the most legally excluded populations — Black people, queer and trans people, disabled people, undocumented and non-citizen immigrants, aging populations — will ask different questions, design different studies, and generate different strategies.

Concretely, this means that equitable treatment research should begin by mapping the legal categories that exclude specific populations, design approaches in partnership with those populations, test those approaches in the settings where those populations actually receive (or are denied) care, and evaluate success by whether the most excluded populations experience measurable improvement — not by whether average outcomes improve while disparities persist or widen.

Methodologically, centering demands changes at every phase of the research process. Sampling strategies should oversample the legally excluded rather than treating them as hard-to-reach subgroups whose absence is noted in a limitations paragraph. Outcome measures should reflect what matters to those populations—sustained housing, reduced criminal legal contact, family reunification, bodily autonomy—not only clinical metrics like abstinence or retention that may themselves reflect the priorities of programming designed without their input. Community advisory structures should hold genuine decision-making authority over research design and dissemination — not serve as consultative ornaments whose sign-off is recorded and then set aside (111, 112).

And, perhaps most importantly, the legal mapping that precedes treatment design should be conducted with the communities it describes, because the people navigating compound legal exclusion possess knowledge about how categories interact that no legal dataset can capture. Recovery programming built for and validated on white male opiate users cannot be adopted wholesale for populations facing intersectional disadvantage. Cultural relevance is a structural question, not a sensitivity training question. It means designing from the margins, not adapting from the center.

Discussion

The substance use treatment gap is not an implementation problem. It is a legal one. Law constitutes the categories through which the treatment system is organized. Legal categories were forged through a century of racialized drug policy and continue to operate as mechanisms of racial formation, sorting populations into tracks of care and abandonment along lines of race, gender, sexuality, disability, citizenship, and age. Recognizing this reorients, rather than dismisses, the importance of clinical skill, organizational capacity, and provider commitment. It clarifies what those efforts are working against — and what changing the ceiling, not just working beneath it, would require.

I am not claiming law is the only force shaping the treatment gap. I am claiming it is a different kind of force — one that creates the terrain on which every other force moves. They operate within the field it creates, and they cannot move its walls. Stigma, provider reluctance, and organizational capacity operate within a legally constituted field whose boundaries they cannot themselves change. Removing legal barriers is a necessary but not sufficient condition for equity — and that necessity is what existing structural determinants frameworks have not named.

The tension this article cannot resolve is worth naming directly. The implications outlined above are largely reformist: eliminating the inmate exclusion, authorizing harm reduction, and restructuring Medicaid continuity through reentry. Wahbi and Beletsky (113) argue that even ostensibly medical alternatives to incarceration — including coercive SUD treatment — extend carceral reach rather than disrupt it, and that genuine alternatives must be centered on liberation, not the dispersal of punitive power into clinical settings. Woodall and Boeri (114) press the point from lived experience, finding that drug courts and treatment-enforcement collaborations function as carceral extensions regardless of their clinical framing. Spade (), Kaba (), Davis (108), and James (86) ground this in the structural argument: if the legal categories were designed to exclude, making them more inclusive may extend the reach of the system without transforming the logics that produced exclusion in the first place. These are not reasons to forgo reform — people are dying now. But the harder question must be held alongside the pragmatic one: is the goal to treat better within existing legal categories, or to create legal categories worthy of the people they govern?

The answer is both — but the second question must discipline the first. The standard against which clinical and policy strategies should be evaluated is not whether they improve average outcomes, but whether they dismantle the legal frameworks that produce racialized disparities in who receives care, what kind of care they receive, and whether that care is experienced as healing or as another form of state control. Addiction medicine that begins from the experiences of the most legally excluded populations — and works backward from their needs to the legal and organizational changes required to meet them — will produce different questions, different standards, and different outcomes than the field has generated to date.

Conclusions and recommendations

First, clinical and public health research should integrate legal-epidemiological measures into treatment outcome frameworks as a matter of standard practice. Legal status — coverage eligibility, criminal legal involvement, immigration status, facility licensing — shapes who reaches care before clinical contact occurs. Outcome studies that do not account for these upstream legal conditions will systematically misattribute treatment failure to individual or organizational factors.

Second, dismantling carceral exclusions from MOUD access is both a clinical imperative and a public health emergency. The evidence that drug poisoning is the leading cause of death in the first week after release from incarceration — with crude mortality rates of 657 per 100,000 person-years in that window, across 1.47 million people in eight countries (88) — is not a finding that calls for better discharge planning. It calls for eliminating the inmate exclusion, mandating evidence-based SUD treatment in carceral facilities, and building Medicaid continuity through the transition — not around it.

Third, harm reduction should be treated as a primary clinical strategy, not a last resort or a legally marginal supplement to abstinence-based care. Where harm reduction is prohibited or excluded from benefit packages, that prohibition is itself the problem requiring legal remedy, not organizational workaround.

Several limitations warrant acknowledgment. This is a conceptual argument, and the causal pathways proposed here await empirical operationalization and testing in clinical addiction settings. Second, the analysis centers the United States legal-racial context; the argument’s applicability elsewhere depends on how legal category creation operates under different political and historical conditions. Third, the independent and intersecting force of ableism, transphobia, and xenophobia in structuring the treatment gap receives less sustained attention here than each deserves. I claim this unfinished work. Resolving it begins with the communities bearing the weight of a treatment system built to exclude them — and demands that addiction medicine, public health, and law follow their lead.

Among people with addiction, drug poisoning is the leading cause of death in the first week after release from incarceration — a mortality rate so extreme it would constitute a mass casualty event in any other clinical context. The legal infrastructure producing that outcome is knowable, nameable, and changeable. Medicine has the standing and the obligation to say so. Doing so requires treating law as a clinical variable, legal reform as a treatment strategy, and the populations most systematically excluded as the starting point rather than the afterthought. Congress decided a century ago that some drug users deserved care and others deserved punishment. That decision still organizes who counts as a patient, who counts as a provider, which sites count as legitimate settings, and which practices count as treatment. Law is the super-determinant that shapes the structural determinants of health, housing, employment, criminal legal involvement, immigration status, and insurance access, that in turn decide who reaches any of those four categories. The work ahead is to specify, domain by domain, which legal changes would actually close the gap, and to test whether closing it changes who lives.

Statements

Data availability statement

No original empirical data were generated or analyzed for this article. Further inquiries can be directed to the corresponding author.

Author contributions

EK: Conceptualization, Writing – original draft, Writing – review & editing.

Funding

The author(s) declared that financial support was not received for this work and/or its publication.

Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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The author(s) declared that generative AI was not used in the creation of this manuscript.

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Keywords

addiction treatment, carceral health, harm reduction, health equity, medications for opioid use disorder (MOUD), opioid use disorder, public health abolition, super-determinant of health

Citation

Kerrison EMT (2026) Built to exclude: the law is a super-determinant of racial disparities in addiction treatment. Front. Psychiatry 17:1811329. doi: 10.3389/fpsyt.2026.1811329

Received

14 February 2026

Revised

06 July 2026

Accepted

07 July 2026

Published

30 September 2026

Volume

17 - 2026

Updates

Copyright

© 2026 Kerrison.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Erin Michelle Turner Kerrison, kerrison@berkeley.edu

Disclaimer

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

来源：Frontiers in Psychiatry · frontiersin.org

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