Fabiola Arbelo Cruz, MD, an Addiction Psychiatry Fellow in the Yale Department of Psychiatry, is co-author of the paper, "Racial Inequities in Treatments of Addictive Disorders" published in a recent American Academy of Addiction Psychiatry newsletter.
Last year we all witnessed how Black and Brown lives have been disproportionately affected by the COVID-19 pandemic and police violence. This has reignited conversations across our country, and the world, about racism and its impact. In academic medicine and psychiatry, there are often discussions about disparities in treatment and outcomes, without recognizing the relevant social determinants of health- including racism. Racism is defined by Dr. Camara Jones as “a system that structures opportunity and assigns value based on phenotype (‘race’) or the way people look,” and “unfairly disadvantages some individuals and communities1.” Structural racism, along with white supremacy, class oppression, and gender discrimination leads to power and wealth imbalance across many of the systems that govern our lives, such as housing policy, educational systems, labor markets, the criminal justice system, and many more2. Black and Brown communities have been made vulnerable to disease, psychological stressors, and unhealthy behavior3,4 due to the unequal distribution of resources. This unequal distribution is evident in substance use disorder (SUD) treatment as racism at varying levels in the system has led minoritized groups to be historically and systematically excluded from access to treatment. If we are serious about addressing these inequities in treatment, it is imperative that we understand and recognize how economic, physical and sociopolitical forces impact medical decisions3.
Although many acknowledge substance use as the number one health problem in North America5, data reveals that treatment gaps are enormous. In 2018, only 18% of people identified as needing treatment actually received it6. These gaps are greater for minoritized communities. For Black and Latinx groups in the US, 90% and 92%, respectively, diagnosed with a SUD did not receive addiction treatment7,8. Another study showed that Black patients were 70% less likely to receive a prescription for buprenorphine at their visit when controlling for payment method, sex, and age9. Furthermore, a study of privately insured people who suffered an overdose and were treated at an emergency room found that Black patients were half as likely to obtain treatment following overdose compared with non-Hispanic white patients10. Studies have also shown that despite uniform rates of substance use among racial and ethnic populations, there is a disproportionate rate of drug arrests for Black Americans. For example, cannabis use is equally prevalent among Black and white people, yet Black people are 3.64 times as likely to be arrested for possession11.
The inequities in substance use treatment are multifactorial, but racism is a common thread throughout. Drug policies provide the historical context for how substance use treatment has been viewed, who was able to receive treatment, and in what context. The first major statute of highly punitive drug laws was the Harrison Narcotic Tax Act of 1914, which was established to regulate the distribution of coca and opioids. This law and subsequent jurisprudence were used to prosecute physicians who prescribed opioids for the treatment of addiction12. It also contributed to the conception of risky substance use as a moral and character defect rather than a disease and was the basis for drug policies that stigmatized and criminalized people in need of addiction treatment6. Other policies, like the Anti-Drug Abuse Act of 1986, created the 100:1 sentencing disparity for crack cocaine versus powder cocaine– this led to disproportionately longer sentencing for Black people13. Although recent attempts to change drug policy to address these disparities have been made, inequities in treatment continue to persist.
Other than advocacy for changes in drug policies, what can we do to address these inequities? At the community level, partnerships with local organizations and leaders are critical to increase trust and decrease stigma against SUD treatment. With community engagement and partnership, treatments can be developed that are culturally responsive14,15. Once an individual is in treatment, they should not only receive the standard of care in medication treatment, but also the treatment which is responsive to their cultural, psycho-behavioral, and social needs. This is critical to minimize lapses in treatment and ensure the adequate duration of treatment6. There are several examples of successful culturally responsive interventions14,15. The Motivational Interviewing and Community Reinforcement Approach utilized culturally tailored evidence-based treatments for American Indians and Alaskan Natives for SUD16. Another example, the Imani Breakthrough Recovery Program, is a faith-based initiative designed to be culturally responsive and trauma-informed while assisting Black and Brown communities with SUD, by utilizing wellness coaches and groups held in the local church17. Culturally adapted motivational interviewing that explicitly considers social stressors and cultural influences can help reduce heavy drinking and frequency of related negative consequences among Latinx, particularly those who are less acculturated or encounter higher levels of discrimination18.
At the institutional and organizational level, we must aim to increase the number of specialists trained to provide marginalized and minoritized populations with culturally responsive SUD care. There are training programs that serve as good examples of enhanced curricula in addiction psychiatry and culturally responsive care. REACH (Recognizing and Eliminating disparities in Addiction through Culturally informed Healthcare), a SAMHSA-funded program based at Yale, is a 1-year program for medical students, psychiatry residents/fellows, APRN/NP trainees, and PA trainees who identify from an underrepresented group in medicine17,19. ACCESS (Achieving Culturally Competent and Equitable Substance use Services), is a Boston University School of Medicine/Boston Medical Center Health Resources and Services Administration funded initiative for psychiatry and psychology trainees to treat individuals with co-occurring mental illness and SUDs at federally qualified health centers. Staff at the health centers also attend seminars by ACCESS trainees on working with diverse patient populations who have co-occurring mental illness and SUDs19.
It is important to recognize racist structures and policies that contribute to current inequities in SUD treatment. Although the causes of these inequities are deeply historically rooted, we should not languish in complacency. Several actions can reduce these inequities, including advocacy, community partnerships, and increasing knowledge on providing culturally responsive care. If clinicians want to provide anti-racist and equitable care, these steps are imperative in matching words with action. It is truly a matter of life and death.
- Jones CP. Confronting Institutionalized Racism. Phylon 1960-. 2002;50(1/2):7. doi:10.2307/4149999
- Chadha N, Lim B, Kane M, Rowland B. Toward the Abolition of Biological Race in Medicine. Other & Belonging Institute. https://www.crg.berkeley.edu/wp-content/uploads/2020/07/TowardtheAbolitionofBiologicalRaceinMedicineFINAL.pdf. Published May 2020. Accessed May 10, 2021.
- Metzl JM, Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Soc Sci Med. 2014;103:126-133. doi:10.1016/j.socscimed.2013.06.032
- National Academy of Science, Engineering, and Medicine. The Root Causes of Health Inequity. Communities in Action: Pathways to Health Equity. http://www.ncbi.nlm.nih.gov/books/NBK425845/. Published January 11, 2017. Accessed April 30, 2021.
- The Robert Wood Johnson Foundation (2013). Substance Abuse. The Nation’s Number One Health Problem. Available at: https://files.eric.ed.gov/fulltext/ED476048.pdf. Accessed May 10, 2021
- Jordan, A, Mathis, ML, Isom, J. (2020) Achieving Mental Health Equity: Addictions. Psychiatric Clinics of North America, 43(3), 487-500. https://doi.org/10.1016/j.psc.2020.05.007
- Substance Abuse and Mental Health Service Administration. 2019 National Survey on Drug Use and Health: African Americans. https://www.samhsa.gov/data/sites/default/files/reports/rpt31099/2019NSDUH-AA/AfricanAmerican%202019%20NSDUH.pdf . Published Sept 2020. Accessed April 7,2021.
- Substance Abuse and Mental Health Service Administration. 2019 National Survey on Drug Use and Health: Hispanics, Latino or Spanish Origin or Descent. https://www.samhsa.gov/data/sites/default/files/reports/rpt31101/2019NSDUH-Hispanic/Hispanic%202019%20NSDUH.pdf. Published Sept 2020. Accessed April 7,2021.
- Lagisetty PA, Ross R, Bohnert A, Clay M, Maust DT. Buprenorphine Treatment Divide by Race/Ethnicity and Payment. JAMA Psychiatry. 2019;76(9):979–981. doi:10.1001/jamapsychiatry.2019.0876
- Kilaru AS, Xiong A, Lowenstein M, et al. Incidence of Treatment for Opioid Use Disorder Following Nonfatal Overdose in Commercially Insured Patients. JAMA Netw Open. 2020;3(5):e205852. doi:10.1001/jamanetworkopen.2020.5852
- A Tale of Two Countries: Racially Targeted Arrests in the Era of Marijuana Reform. American Civil Liberties Union. https://www.aclu.org/report/tale-two-countries-racially-targeted-arrests-era-marijuana-reform. Published April 20, 2020. Accessed May 13, 2021.
- King RG. The Narcotics Bureau and the Harrison Act: Jailing the Healers and the Sick. Yale Law J. 1953;62(5):736. doi:10.2307/793503
- Sacco LN. “Drug enforcement in the United States: history, policy and trends,” congressional research service 2014. Available at: https://fas.org/sgp/crs/misc/ R43749.pdf. Accessed May 10, 2021.
- Substance Abuse and Mental Health Service Administration. The Opioid Crisis and the Black/African American Population: An Urgent Issue. https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-05-02-001_508%20Final.pdf. Published April 2020. Accessed January 13, 2021.
- Substance Abuse and Mental Health Service Administration. The Opioid Crisis and the Hispanic/Latino Population: An Urgent Issue. http://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-05-02-002_0.pdf. Published July 2020. Accessed April 30, 2021.
- Venner KL, Serier K, Sarafin R, et al. Culturally tailored evidence-based substance use disorder treatments are efficacious with an American Indian Southwest tribe: an open-label pilot-feasibility randomized controlled trial. Addiction. 2021;116(4):949-960. doi: https://doi.org/10.1111/add.15191
- Ed Stannard. Spiritual program brings people out of depths of addiction. New Haven Register. https://www.nhregister.com/news/article/Spiritual-program-brings-people-out-of-depths-of-13343417.php. Published October 28, 2018. Accessed May 13, 2021.
- Lee, C. S., Colby, S. M., Rohsenow, D. J., Martin, R., Rosales, R*.,et al. (2019). A randomized controlled trial of motivational interviewing tailored for heavy drinking Latinxs. Journal of Consulting and Clinical Psychology, 87(9), 815- 830. http://dx.doi.org/10.1037/ccp0000428
- Durham M. Racial Inequities in Substance Use. Providers Clinical Support System. February 2021. https://pcssnow.org/event/racial-inequities-in-substance-use/. Accessed May 13, 2021.