Since the 1950s, substance use has been medically defined as a psychopathology (1). While early definitions once categorized addiction as a “sociopathic personality disturbance” (2), distinct substance abuse and substance dependence labels have existed since 1980 with the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (1, 3). Despite the establishment of a biomedical model of substance use, views of substance use as a personal moral failing have persisted in both the public and medical spheres (4). The moral rhetoric against individuals with substance use disorders (SUDs) goes hand in hand with perceptions that substance use warrants punishment; when paired with prejudice and animosity, these beliefs lay the foundation to target groups of people with the selective enforcement of drug laws, as seen with the US War on Drugs (5). Policies that ignore public health recommendations and employ racism—such as Nixon’s refusal to deschedule and decriminalize cannabis in the 1970s—mold “moral failings” into systemic tools of oppression (6). Hence, it is vital to reject unfounded beliefs about individuals with SUDs that get entangled with racism, which must begin with the scientific community.

Unfortunately, biomedical researchers often report race-related findings without critically considering the systems driving their observations (7–11). Social epidemiologist Dr. Nancy Krieger describes this dilemma as a two-edged sword, where the omission of race data from investigations ignores existing injustice, and the mishandling of race data exacerbates further injustice, reinforcing harmful beliefs about marginalized groups (12, 13). Investigators fall short by not incorporating anti-racist, equity-focused frameworks into their work, such as Critical Race Theory (CRT). Originally a framework for legal analysis, CRT underscores the relationship between race, racism, and power and denotes many ways in which oppression manifests across all forms of expression (14), providing language to examine how social, political, and historical forces give race meaning as a construct (see Table 1 for CRT tenets and principles). Frameworks like CRT can be used to recognize structural racism and racialization as the drivers of differential health outcomes, not race. This gets at a fundamental limitation of the biomedical model of substance use: the model minimizes the impact of psychosocial factors on SUDs (17); in turn, this risks positioning race as a biological driver of SUDs.

Therefore, in order to engage with race data with diligence, substance use researchers must employ anti-racist praxes in their investigations. Given that many research institutions have been created and maintained through white supremacy, anti-racist progress requires transformative action driven by the perspectives and priorities of minoritized communities (18). Drawing on concepts from the Public Health Critical Race praxis (PHCR) (13), QuantCrit (15), and an anti-racism research framework from Goings and colleagues (16), we recommend a set of guidelines to help biomedical researchers conceptualize and engage with race more responsibly in substance use research (SUR).

The use of race as a broad proxy for structural racism can be extremely harmful to minoritized groups, thereby reinforcing racialized stigma and perpetuating biological determinism (7). Whether explicit or implicit, any use of biological determinism has no place in published literature (7). Across biomedical SUR literature, few studies systematically evaluate whether substance use researchers appropriately define race or report race data. In a recent scoping review of studies from 2000 to 2020 involving maternal–infant dyads with Opioid Use Disorder, investigators found that of the 63 identified quantitative studies that used race/ethnicity in their statistical analyses, only 17 mentioned race/ethnicity in their discussion sections (8). None of the included studies defined race as a social construct, leaving the authors to conclude that SUR “can benefit from a reckoning with how poorly race data have been incorporated to date” (8).

While there are limited critical evaluations of anti-racism in SUR, publications in adjacent health sciences fields highlight a concerning pattern. For example, a systematic review of 329 epidemiology studies published in five prominent journals from 1995 to 2018 found that 61% of studies failed to justify using race or ethnicity data (9). In more recent publications from 2020 to 2021, a review of 192 epidemiology studies revealed that only 23% of articles discussed systemic mechanisms that might drive observed racial health disparities (10). Perhaps even more concerning, three of the identified articles considered biological mechanisms as reasons for racial disparities (10). Similar trends are seen across both public health and medical journals; with broad failures to discuss the role of structural racism in driving health disparities, suggesting that these practices are not outliers but instead the norm (11, 19).

The direct link between intersectional oppression and racial health inequity has been recently recognized as a public health crisis (20–22). While institutions like the National Institutes of Health have proposed direct commitments to address racial health inequity in research moving forward (19, 23), such commitments have not yet translated into tangible changes in published biomedical research. Anti-racist research frameworks are especially needed for biomedical SUR, where (1) racism is deeply intertwined with the moralization of substance use, and (2) research findings shape public perceptions, institutional norms, federal policies, and biases from medical providers (4, 24). To this end, we outline a foundational set of guidelines on conducting anti-racist research in the following sections, drawing on principles from PHCR (13), QuantCrit (15), and a framework on conducting anti-racist research (16) (see Table 1 for definitions and tenets/ principles of these frameworks).

As scientists, our paradigms must reflect the consensus that systemic oppression and social conditions are the drivers of health inequity, otherwise scientific racism persists (7). The many factors that contribute to health disparities (e.g., neighborhood disadvantage) often go unmeasured and ignored with typological thinking in epidemiological studies related to substance use (47); letting researchers “off the hook” from identifying the structural and political forces that give rise to racial social stratification (48). Even when studies do consider some social conditions like the impact of social class on health, they still sidestep addressing structural racism by placing class and race as independent and mutually exclusive of one another, rather than acknowledging their intersectional relationship (38, 49). When researchers omit systemic context, BIPOC populations bear the consequences of structural racism, like lower rates of opioid medication receipt following inpatient admissions compared to white populations, and widening overdose rates (50–52). Hence, it is critical to dismantle the systems that sustain racism and racialization through the use of anti-racist, CRT-informed approaches in SUR.

An interconnection between theory and practice toward social justice must be at the forefront of SUR, from project ideation to implementation. Although there are challenges to integrating anti-racist research into practice that require further attention (e.g., securing funding for community engagement, balancing time-intensive methodologies with systemic pressures for frequent publications), it is nonetheless crucial that we redefine institutional norms to disrupt oppressive systems (16, 53). This includes moving beyond the biomedical model of substance use and shifting the focus of health inequity from race to racism (13, 15–17). While this paper aims to help substance use researchers engage with race more responsibly, we are not the first to make such a call to biomedical researchers, nor are the guidelines presented here exhaustive [e.g., see (38) for considerations on how researchers can operationalize race and ethnicity]. However, given the scarcity of publications systematically examining how the field of SUR handles race, it is necessary to have ongoing, evolving discussions about what anti-racist practices look like within SUR, as seen in adjacent fields [see (10, 13, 15, 16, 38, 54)]. In addition to conducting future systematic reviews, the field must also work to place a greater emphasis on the collective uplift of historically marginalized communities, especially concerning the applicability, acceptability, and community usability of research findings. As noted by race, gender, and law scholar Dorothy Roberts, “Race persists neither because it is scientifically valid nor because its invalidity remains to be proven. Race persists because it continues to be politically useful” (55). It is therefore our duty as substance use researchers to integrate anti-racism into our work in efforts to disentangle racialization from the moralization of substance use, thereby disarming structural racism as a tool of oppression.

The original contributions presented in the study are included in the article/supplementary material; further inquiries can be directed to the corresponding author.

JL: Conceptualization, Writing – original draft, Writing – review & editing. DB: Writing – original draft, Writing – review & editing, Conceptualization. AM: Writing – original draft, Writing – review & editing, Conceptualization. CC-I: Writing – original draft, Writing – review & editing, Conceptualization. SM: Writing – original draft, Writing – review & editing. AR: Writing – original draft, Writing – review & editing, Conceptualization, Supervision.