The COVID-19 pandemic has led to sharp increases in drug and alcohol misuse, overdose, and worsening of behavioral health disorders in the United States and abroad. A CDC survey revealed that 13% of individuals reported beginning or escalating substance use, including alcohol use, in June 2020 due to COVID-related stress and other emotional factors.1 Black and Hispanic persons reported higher substance use compared to white or Asian persons in the survey.1 More recent data indicates that Black individuals with substance use disorder (SUD) – which includes Alcohol Use Disorder (AUD) and Opioid Use Disorder (OUD) – are at higher risk for COVID-19 and related health complications and death compared to white individuals.2

Long-standing misconceptions regarding low prevalence of substance misuse and use disorder among underrepresented groups have contributed to racially unequal treatment access. This population currently includes those who identify as Black, Indigenous, and People of Color (BIPOC). It should be noted, among People of Color, there is little research data on behavioral health issues within Arab American and South Asian American populations. (See also, a psychiatry resident’s take on Asian American racism.)

Drug and Alcohol Use Prevalence by Race

Opioid Misuse

While opioid overdose deaths have disproportionately impacted white Americans, there has been a significant rise in opioid-related overdoses among Black Americans in the past 5 years (43% Black compared to 22% white).3 According to the Substance Abuse and Mental Health Services Administration (SAMHSA), in 2017, Black individuals had the highest rates of opioid and synthetic opioid-related overdose fatalities compared to other racial/ethnic groups.4 In the same year, American Indians and Alaska Natives had the second-highest rate of opioid overdoses and the third-highest rate of overdose deaths from synthetic opioids across all racial/ethnic groups.5

Other Drug and Alcohol Use

Further, data from 2019 National Survey on Drug Use and Health (NSDUH) – the most recent available – of adults 18 years and older reports prior-year use or misuse as such (*percentages are rounded; not all stats are available for all populations):6

  • American Indian & Alaska Natives: 25% (344,000) misused illicit drugs, 20% (314,000) used marijuana, 6% (98,000) misused psychotherapeutic drugs, 5% (80,000) misused opioids, 5% (10,000 of 18-25-year-olds) misused prescription stimulants, 6% (72,000) reported heavy alcohol use, 7% (95,000) reported AUD, and 10% (142,000) reported an SUD while 4% (52,000) had both an SUD and a mental illness, 8% (40,000 aged 26-29) had a serious mental illness (SMI) and 7% (35,000 aged 26-49) experienced major depressive episodes
  • Black or African Americans: 22% (6.7 million) misused illicit drugs; 20% (6.4 million) used marijuana, 4% (1.4 million) misused psychotherapeutic drugs, 3% (1.1 million) misused opioids, 2% (111,000 of 18-25-year-olds) misused prescription stimulants, 11% (252,000) reported misuse of both drugs and alcohol, 4% (1.2 million) reported heavy alcohol use, 5% (1.5 million) reported AUD, and 8% (2.3 million) reported an SUD while 3% (947,000) had both an SUD and a mental illness, 5% (630,000 aged 26-49) had a serious mental illness and 7% (877,000) experienced major depressive episodes
  • Hispanic or Latinos: 19% (7.8 million) misused illicit drugs, 15% (7.2 million) used marijuana, 4% (1.8 million) misused opioids, 3% (260,000 18- to 25-year-olds) misused prescription stimulants, 13% (386,000) reported misuse of both drugs and alcohol, 5.1% (1.9 million) reported heavy alcohol use, 5% (2.1 million) reported AUD, and 7% (2.89 million) reported an SUD while 4% (1.4 million) had an SUD and a mental illness, 5% (1.1 million) aged 26-49 had a serious mental illness and 7% (1.3 million) experienced major depressive episodes
  • Non-Hispanic or Latino Whites: 22% (34.9 million) misused illicit drugs, 19% used marijuana, 7% (11.2 million) reported heavy alcohol use, 6% (9.5 million) reported AUD, and 8% (12.7 million) reported an SUD

For the same time period, 2.8 million (1.8%) whites reported receiving substance use treatment in the year prior compared to 468,000 (1.6%) Black or African Americans; 27,000 (1.9%) American Indian & Alaska Natives; and 448,000 (1.1%) Hispanic or Latinos.

According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), Black, Hispanic, and American Indian individuals are substantially more impacted by alcohol in comparison to other ethnic groups.7 Also, while white and Native American populations experience higher rates of alcohol dependence – Black, and Hispanic individuals once dependent, have greater rates of persistent dependence and relapse compared to White individuals.7

Even with evidence of continual increases in the prevalence of substance misuse, SUD, and overdose deaths among underrepresented groups – screening, assessment, and access to treatment for these communities remains unequal in many parts of the country.

Addiction Treatment: Factors that Block Access and Hinder Outcomes for BIPOC Individuals

Drug and alcohol use disorder (AUD) treatment disparities and barriers stem from multilayered internal (eg, familial and cultural stigma) and external (eg, racism and socioeconomic challenges) factors. External systemic issues also include poverty, law enforcement encounters, poorer healthcare access, along with institutional and regulatory barriers.7,8

Screening and Brief Intervention Gaps

Lack of screening and brief intervention (SBI) for alcohol and drug use by primary care providers in BIPOC communities also contributes to gaps in early intervention opportunities.  For example, a 2018 study by Venner and a group of family physicians in New Mexico serving primarily Latino/Hispanic and Native American communities, found that only 25% of clinicians screened patients for drug and alcohol use at every visit. The clinicians surveyed indicated that they screened patients they viewed to have higher SUD risk rather than low to moderate risk behavior (a much larger group), missing key screening opportunities. 9

Racism and Trauma in Behavioral Health

According to the American Society of Addiction Medicine (ASAM), historic systemic racism influences lived experiences for Black, Indigenous, and certain groups of People of Color and their risk for developing SUD, access to treatment, and health outcomes.10

Studies show that racism, discrimination, stress, and trauma faced by Black, Indigenous, Hispanic, and Latino groups leads to greater risk of behavioral health conditions such as post-traumatic stress disorder, depression, anxiety, and substance misuse.11-13 Black women, in particular, are vulnerable to greater risks and challenges with SUD stemming from stress and trauma.14 In addition, clinician bias, stereotypes, and lack of racial/ethnic diversity in treatment program staff negatively impacts patient interactions, treatment retention, and trust.4 (See also, our report on media exposure and vicarious racism.)

Emily Einstein, PhD, chief of Science Policy at the National Institute on Drug Abuse (NIDA) and co-lead of the NIDA Racial Equity Initiative, told Psycom Pro: “There is a history of racial bias and discrimination around drug use in this country. Who is considered a ‘patient’ and who is considered a ‘criminal’ is a fraught societal issue that plays out in doctor’s offices, emergency departments, hospitals, courtrooms, prisons, and beyond. Although statistics vary by drug type, overall, white and Black people do not significantly differ in their use of drugs, yet the legal consequences they face are often very different.”

Dr. Einstein, pointed out, “Even though they use cannabis at similar rates, for instance, Black people were nearly four times more likely to be arrested for cannabis possession than white people in 2018.15 Of the 277,000 people imprisoned nationwide for a drug offense in 2013, more than half (56%) were African American or Latino even though together those groups accounted for about a quarter of the US population.” 16

She went on to say, “During the early years of the opioid crisis in this century, arrests for heroin greatly exceeded those for diverted prescription opioids, even though the latter—which were predominantly used by white people – were more widely misused.17 It is well known that during the crack cocaine epidemic in the 1980s, much harsher penalties were imposed for crack (or freebase) cocaine, which had high rates of use in urban communities of color18, than for powder cocaine, even though they are two forms of the same drug.19 These are just a few examples of the kinds of racial discrimination that have long been associated with drug laws and their enforcement.”20

Adina Bowe, MD, a board-certified physician in Internal Medicine, Psychiatry, Addiction Medicine, and Addiction Psychiatry, and chairperson of American Academy of Addiction Psychiatry’s Equity, Diversity and Inclusion Committee added, “If you’re not impacted by racism, you’re blind to it.” She pointed out that “factors such as poverty, educational level, housing, and language barriers faced by BIPOC individuals all affect access and quality of care.”

Dr. Bowe went on to note additional factors tied to systemic racism that have led to ongoing disparities in prevalence, access to care, and outcomes for many behavioral health disorders:

  • cultural and familial stigma surrounding behavioral health (in ADHD for example)
  • the racial and ethnic groups who are underrepresented in medicine (URM) as providers
  • the dearth of research and funding for certain BIPOC groups

See also, Psycom Pro’s special series on structural racism and mental health.

Medication-Assisted Treatment and Unequal Access to Care

Even when they are properly diagnosed and seek care, BIPOC individuals often face challenges accessing medication-assisted treatment (MAT) for opioid use disorder (OUD). Methadone, buprenorphine, or naltrexone may be used in MAT. Studies have shown methadone and buprenorphine are effective for OUD treatment and overdose prevention in comparison to abstinence-based treatment.21

However, MAT access varies based on:22-24

  • race/ethnicity
  • ability to pay
  • where someone lives
  • discriminatory drug regulations and policies
  • marketing strategies for the medications

Studies have found that people on buprenorphine treatment are more often white and have higher educational and income status compared to people on methadone treatment at the national level.25,26 A 2018 study by Stein et al determined that Medicaid enrolled individuals in 14 states (2002-2009) had much higher buprenorphine treatment access in rural counties with less poverty and lower concentrations of Black and Hispanic populations.27

Regulations for distribution of methadone are more restrictive compared to buprenorphine (see the latest buprenorphine prescribing waiver rules). Methadone access is only through opioid treatment programs (OTP) with strict in-person supervised distribution. In comparison, buprenorphine can be prescribed by clinicians, including advanced practice providers, and accessed through pharmacies.28

Stark contrasts in marketing strategies for buprenorphine (ie, white middle-class advertising campaigns) versus methadone (ie, urban locations serving low-income populations) have also greatly contributed to disparities in OUD treatment access and stigma.28

Adding to access issues, a 2020 study reported there are more than 18,000 clinics providing buprenorphine and only around 1,700 clinics providing methadone. The researchers also found that a majority of methadone treatment clinics are in mainly Black and Hispanic/Latino neighborhoods, while buprenorphine treatment programs are in mainly white neighborhoods.29

Inequalities also exist in treatment retention and completion among certain underrepresented groups. Black and Hispanic individuals undergoing treatment for OUD have lower treatment completion compared to white patients.30

Drug and Alcohol Addiction: A Word about Temporary Fixes

Aaron Williams, senior director of Practice Improvement & Consulting with the National Council for Mental Wellbeing, says, “There are layers of stigma around addiction and treatment medications. Our country has historically focused on abstinence-based treatment which adds to barriers toward MOUD treatment acceptance by patients, clinicians, and communities.”

He added, “Addiction treatment is viewed by many as a car wash, you go into treatment, get clean and come out – end of medication treatment… It is not viewed as a chronic condition needing long-term support medication. If you compare treatment for high blood pressure, for example, a provider won’t take a patient off blood pressure medication after a period of time. They will take an evidence-based approach. It should be the same standard for addiction treatment as a chronic condition.”

Addiction Treatment and Racial Equity

Recent discussions and media attention have heightened awareness about access and equity gaps among communities of color, which are slowly helping to lower some barriers (infrastructure, funding, provider, and community needs).

“On a continuum, we are at the beginning stage for behavioral health access equity,” said Williams. “We need to recognize we have a long way to go for equity for all individuals. But I am hopeful we are making progress through policy changes and increased awareness to reframe conversations and language on how we talk about addiction.” He added, “Policymakers are looking at how to address addiction from a public health lens rather than a criminal justice lens.”

The Role of Certified Community Behavioral Health Clinics (CCBHCs)

Certified Community Behavioral Health Clinics (CCBHCs) offer one potential solution. The program launched in 2017 with 66 clinics in 8 states. These clinics are helping to bridge access gaps for mental health and SUD treatment and increase equity in care. According to the National Council on Mental Wellbeing (NCMW), there are currently 340 active CCBHC’s operating in the US.31

These clinics meet crucial community behavioral health needs for complete addiction and mental health treatment services. They receive different types of funding and support including Medicaid reimbursement.

Based on survey data from the NCMW, CCBHC’s have several benefits for a community:31

  • CCBHC’s increased the number of people they serve – 17% more Americans are being engaged by CCBHCs compared to pre-CCBHC levels.
  • faster treatment access (50% are able to provide same-day access to care, and 84% provide access within 1 week, compared to an average 48-day wait among behavioral health providers nationwide)
  • workforce expansion (hire culturally concordant staff, translators, peer coaches)
  • initiate or expand medication treatment services for SUD
  • address health disparities in communities of color

Williams noted, “The COVID-19 pandemic has created changes to methadone distribution policies such as allowing for more days of take-home doses and lockbox delivery of doses. Future research needs to ascertain if lockbox delivery and other concepts developed due to the pandemic can be widened for greater access.”

NIDA’s Racial Equity Initiative

NIDA’s Einstein pointed to NIDA’s Racial Equity Initiative which “has identified stigma, discrimination, and prejudice in the context of substance use disorders and treatment as a top research priority.” The institute is “redoubling its focus on vulnerabilities and progression of substance use and addiction in minority populations. We are exploring research partnerships with state and local agencies and private health systems to develop ways to eliminate systemic barriers to addiction care. We are also funding research on the effects of alternative models of regulating and decriminalizing drugs in parts of the world where such natural experiments are already occurring,” she says.

Policy & Flexibility

Despite these initiatives, there are still multiple layers of barriers contributing to unequal access to treatment for many BIPOC individuals with behavioral health disorders including AUD, OUD, and SUD. It is important for addiction treatment programs, providers, lawmakers, and communities to recognize and increase efforts to address systemic socio-economic, cultural, and ethno-racial factors that lead to treatment inequities.

As Dr. Bowe stated, it’s important to take multifactorial approaches to dismantle barriers. She suggests the following:

  • Remove policy and regulatory barriers that impede access to treatment
  • Improve training and education of clinicians to destigmatize addiction, recognize and address implicit bias (more on cultural humility)
  • Enhance medical education and CME programs for clinician training and education on substance misuse and addiction
  • Raise clinician awareness of treatment program resources available in their state to make program referrals
  • Incentivize more clinicians of color to become behavioral health providers, particularly serving rural areas
  • Educate the public about addiction, along with behavioral health treatments, to lower stigma, bias, and stereotypes

Dr. Bowe also recommends flexibility with in-person counseling requirements and methadone access for OUD treatment, which she believes will lower barriers and improve program retention. For example, she points to “utilizing telehealth and alternate methadone delivery programs so an individual doesn’t have to miss work to attend counseling and receive medications.”

Addiction Terminology

Dr. Einstein adds that the way we talk about substance use and related disorders is crucial. “There must be wider recognition that addiction is not a moral failing, and that people with substance use disorders are deserving of quality care – just as people with any other health condition. Often unintentionally, many people still talk about addiction in ways that are stigmatizing. In addition, it is necessary for healthcare providers to receive training in caring for people with substance use disorders. This will ensure that clinicians are comfortable and prepared to provide compassionate and competent care for people with substance use disorders.”

Cultural Aspects of Addiction

Cultural aspects of addiction rooted in familial, religious, and spiritual aspects such as coping skills, effects of trauma, treatment outreach can all affect drug and alcohol addiction treatment goals. It’s essential for providers, policymakers, and governmental bodies to incorporate racial impact assessments and cultural context in substance-related policy proposals. (See also, how culture can impact an ADHD diagnosis.)

Behavioral Health Workforce & Training: Widening BIPOC Representation

Lastly, Einstein points to diversity of the workforce and training pipeline as another goal within NIDA’s racial equity initiative. The group aims to increase awareness of SUD care as a career for BIPOC and support their training. Goals also include “identifying and addressing barriers to their academic and professional success within the field and partnering with professional societies to combine our efforts to increase diversity,” says Einstein.

At the end of the day, “policymakers, clinicians, and researchers should strive to be aware of how insidious, systemic racial and ethnic biases influence the system and impact individuals.”

Clinical Tools and Resources

 

 Editor’s Note on terminology: The term “underrepresented” is used in place of minorities except for direct quotes or research citations.

 

 

References
Last Updated: Jul 1, 2021