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

The United States built an evidence-based substance use treatment system that works, just not for everyone. Fewer than one in five adults who needed treatment in 2024 received any form of care, including medications for opioid use disorder (MOUD), and Black and American Indian/Alaska Native communities died of drug overdose at the highest rates. This article argues that closing the gap rests on recognizing law as a super-determinant of population health: not a contextual influence but a constitutive force that creates the categories through which treatment is organized. Drawing on constitutive legal theory, racial formation, Public Health Critical Race Praxis, and administrative violence, it shows how law defines who is eligible for care, who may provide it, which facilities are recognized, and which practices count as treatment, and how each category was forged through a century of racialized drug policy. The article traces these legal categories across four domains — people, providers, settings, and interventions — and demonstrates how they converge to yield racially sorted treatment environments in community and carceral settings alike. It argues that addiction medicine must integrate legal analysis and critical race methodology as core competencies, treat legal and policy reform as treatment strategies, and center the most legally excluded populations as the starting point for equitable care. Drawing on abolitionist frameworks in public health and drug policy, it insists that reforms be evaluated not by whether they expand access within existing categories, but by whether they dismantle the arrangements that produce racialized exclusion in the first place.