LET’S LEVEL THE PLAYING FIELD, SHALL WE?

Certain populations are disempowered by a systemic bias against them. As opioid overdose death rates spike at unprecedented levels, marginalized people of color are not only dying at higher-than-usual rates (Panchal, 2023) but also have trouble gaining access to optimal detox and rehab treatment centers and recovery protocols (Saloner & Cook, 2013).

This paper first looks at the wicked problem of substance use disorder (SUD) as it currently exists in 2026 and the people it impacts most heavily; then, it explores some novel and innovative ways in which some very proactive agencies have drawn upon drug treatment and rehabilitative best practices to formulate both policy and measures seeking to give those beset by SUDs and the mental health issues oftentimes occurring concurrently with drug misuse a fighting chance; and lastly, it highlights the efforts to break down institutional silos between human service agencies and thereby improve access to services for racialized communities and other disadvantaged populations deemed “at-elevated-risk” or “already in-crisis."

”The best evidence to date suggests that systemic racism operates at institutional, social, and psychological levels in ways that shape numerous health outcomes” (Suntai et al., 2020) and has caused minority groups to be systemically and repeatedly denied access to SUD treatment” (Yale School of Medicine, 2021). Data will show that African Americans, Indigenous peoples, and Hispanics face more obstacles to accessing treatment services, lower completion rates, and lesser satisfaction with care as compared to Whites (Mennis et al., 2016). If we are to attentively and responsibly address these inequities in treatment, we must identify how economic, physical and sociopolitical forces impact life-and-death medical decisions (Yale School of Medicine, 2021) and meet them head-on with multi-disciplinary team and community-based interventions that are more multiculturally mindful.

Opioid use and opioid overdose fatalities continue to rise among racial/ethnic minorities. With the Social Determinants of Health (SDoH) negatively impacting these poorer communities, unacceptable treatment outcomes are sadly the norm. “Research is needed to investigate how to overcome the disproportionate and deleterious impact of social determinants of health on treatment entry, retention, drug use, and related outcomes among racial/ethnic minorities” (Burlew et al., 2021, p. 2).

Institutional and agency policies founded upon systemic bias do little to assuage the fears of Black or Indigenous populations who feel unease with entering SUD treatment protocols which further stigmatize the Black or Brown addict or alcoholic. The preponderance of the literature points to a SUD healthcare workforce that is grossly lacking in terms of cultural competency. This adversarial condition results in negative health and wellness results and highlights “the need for culturally appropriate treatment programs to enhance treatment program retention and associated positive post-treatment outcomes” (Mennis et al., 2016, p. 158). Best practices in SUD treatment point to the need for services to be distributed more equitably among racial groups and in ways that are more culturally attuned to “remedying the long-standing, multigenerational consequences of punitive and discriminatory systemic factors” (Farahmand et al., 2020, p. 495) that drive harmful and deleterious health outcomes and rates of SUD remission (Recovery Research Institute, 2022).

By way of illustration, and boiled down to its most basic numbers, an analysis of our pernicious national problem reveals the following: 1) The percent of our prison population identifying as Black, Latino, or Indigenous 85% (US Department of Health and Human Services, 2022); 2) The percent of the Black prison population with a diagnosed SUD is 60%, and, 3) The percent of the prison population who are Black: 38% vs. percent of the U.S. population who are Black: 13% (Prison Policy Initiative, 2022). These stunningly disproportionate figures reveal the discriminatory nature of how America misdiagnoses and treats its problem with people of color who, through no fault of their own, may be suffering from a disease for which there is no known cure and get in trouble with the law because of it. Having an SUD is stigmatizing enough; having one intersected by being Black or Brown at the same time is doubly troublesome.

What promotes change? In terms of someone suffering from SUD, removing one’s ambivalence toward using. In terms of needed policy proposals, getting in front of influential lawmakers, community stakeholders, and those who reside in the halls of power and making addiction reform objectives more attuned to the times in which we live. There exist blueprints for success in personal and social action that can break down the barriers holding marginalized populations back. Reform must come so that recovery is embraced through the lens of egalitarianism, beneficence, inclusion, and mindfulness. Innovative, evidence-based, and solution-focused interventions should be accessible to all, not in the onerous, maladaptive ways in which top-drawer Mental Health / Substance Use Disorder treatment is currently doled out along racial divides.

Making things exponentially worse, a racialized population beset by substance use disorders is on the outside looking in when it comes to relevant treatment practices. “The most commonly reported treatment barrier was co-morbid substance use disorders” (Stein et al., 2015, p. 1361) that act as a barrier to blue chip treatment, especially when considering marginalized populations cut off from mainstream healthcare. It’s no wonder, then, that “Blacks and Hispanics take longer to complete outpatient SUD treatment than Whites” (Mennis et al., 2019). Language barriers are one thing; outright racism is quite another.

Racial disparities do currently exist in the healthcare arena of SUD treatment. “There is widespread suffering and even death caused by the lack of pain treatment. There is also the potential to further stigmatize racial minorities who do have opioid use disorder. Overshadowing all these factors is the persistent legacy of the nation’s history of deeply rooted, structural racism” (Whelan, 2020).

The Center for Disease Control (CDC) reports that “racial and ethnic minority groups have less access to proven treatments for substance use disorders” and that this disparity owes largely to factors other than the scarcity of rehabilitative services (Center for Disease Control, 2022). The Social Determinants of Health profoundly influence a person of color’s inability to access top-drawer detox and treatment programs. Income inequalities, whatever their source, can negatively impact people from marginalized racial and ethnic groups at a greater level than Whites. This disparity can manifest in food and job insecurity, homelessness, transportation deficits, and, most notably perhaps, poor health insurance. These are real and profound barriers to SUD treatment and other support services. It is, for this reason, that advocacy for these disenfranchised numbers is so critical.

That systemic racism is inherent both in the laws and in our legal institutions of the United States cannot be denied; that it so profoundly impacts our disadvantaged populations is equally implausible in terms of the access denied to drug misusers who do not happen to be white. On a micro-level, my interviews with resident healthcare and civil rights activists reveal that our people of color are slighted, first, by being stigmatized for being black and, secondly, are further alienated by having an addiction issue.

Although much of the literature identifies substance use disorders as America’s number one health hazard, the data reveals enormous gaps in treatment that are racially divided. In 2018, only 18% of people identified as needing treatment actually received it. These disparities are greater for minority communities. For Black and Latinx groups in the US, only 10% and 8%, respectively, diagnosed with a SUD received addiction treatment (Yale School of Medicine, 2021), while Black clients were less likely to initiate treatment than White clients (Acevedo et al., 2012). “Economic, cultural, accessibility, or, potentially, discriminatory, factors may suppress the likelihood of treatment completion for minorities and result in longer treatment durations required for completion” (Mennis et al., 2019, p. 158) or, earlier dismissal from a treatment program owing to suboptimal insurance plans.

Equally indisputable is the notion that not all addicts are “created equal.” We owe it to all those affected by this pernicious malady to tap into solution-based recovery protocols in equitable ways that might level the playing field for the addict of color who simply wants to get clean; and for the racially disenfranchised alcoholic who wants to put the bottle down for good (Morris, 2021). A lasting and impactful recovery arc should not be denied to anyone who seeks it, regardless of their socioeconomic status or ethnicity. Even if accepted into the myriad treatment facilities dotting our national landscape, evidence supports that people of color fare less well in completing treatment. “Completion disparities for Blacks and Hispanics were largely explained by differences in socioeconomic status and, in particular, greater unemployment and housing instability” (Saloner & Lê Cook, 2013). Inadequate insurance plans available to our marginalized populations also factor into the long odds they are up against when seeking quality addictions healthcare. Unsurprisingly, marginalized populations of color “who are incarcerated, homeless, and suffering from a mental illness have markedly higher rates of overdose death” (S. Wakeman, personal communication, September 22, 2020).

WHAT WE CAN DO HERE IN NEW MEXICO:

1. Research indicates that people of color in Albuquerque and across New Mexico frequently experience lower substance use treatment completion rates than white populations. Studies attribute this disparity to systemic barriers, including a lack of culturally competent therapists, unemployment, suboptimal insurance policies, and unequal access to sustained care.

2. Socioeconomic Disparities: National and local health data—including studies tracked by the National Institutes of Health—show that completion disparities for Black, Hispanic, and Indigenous groups are heavily tied to socioeconomic factors like housing instability, transportation issues, poor primary healthcare, and food insecurity.

3. Cultural Competency: Advocates and state reports point to a severe shortage of culturally competent behavioral health providers in New Mexico communities, making it harder for people of color to find therapists who understand their specific experiences. We need a robust and multiculturally aware case management system, because treatment is just one element of what people are dealing with. We currently say: “Stabilize your drug use, get your life together, and we’ll give you access to treatment (or housing or employment).” But many people need stability or resources like housing before they can stop using drugs. Dictating what must be done before treatment creates barriers to recovery. Add stigma and bias, and lack of insurance and limited access to healthcare into that equation, and you get a disproportionately negative impact on African Americans. Everyone should have options and feel like a partner in their treatment plan.

4. The government could embrace harm reduction as part of the continuum of care. Harm reduction services get into the cracks and crevices of a community where formal treatment does not. Research shows that people who are engaged with a harm reduction service provider—be it a needle exchange, safe consumption space, or MAT—are much more likely to go to treatment. And stay there.

5. Lastly, we need to make certain that communities of color and those who are directly affected play a key role as we talk about policy reform. Too frequently, a commission to tackle this issue may have 40 members, and just one is a person of color an/or someone struggling with an SUD. Most of the time when these policies are created, people from the community are not at the table. And if we want to talk about how policies impact BIPOC communities, that lack of representation is a core problem.

DON’T TALK ABOUT ‘EM WITHOUT ‘EM!

References

Acevedo, A., Harvey, N., Kamanu, M., Tendulkar, S., & Fleary, S. (2020). Barriers, facilitators, and disparities in retention for adolescents in treatment for substance use disorders: A qualitative study with treatment providers. Substance Abuse Treatment, Prevention, and Policy, 15(1), 1-13. https://doi.org/10.1186/s13011-020-00284-4

Burlew, K., McCuistian, C., & Szapocznik, J. (2021). Racial/ethnic equity in substance use treatment research: The way forward. Addiction Science & Clinical Practice, 16(1), 1-6. https://doi.org/10.1186/s13722-021-00256-4

Centers for Disease Control and Prevention. (n.d.). Drug overdose deaths rise, disparities widen. Centers for Disease Control and Prevention. Retrieved October 1, 2022, from https://www.cdc.gov/vitalsigns/overdose-death-disparities/index.html

Farahmand, P., Arshed, A., & Bradley, M. (2020). Systemic racism and substance use disorders. Psychiatric Annals, 50(11), 494–498. https://doi.org/10.3928/00485713-20201008-01

Mennis, J., Stahler, G., El Magd, S., & Baron, D. (2019). How long does it take to complet outpatient substance use disorder treatment? disparities among blacks, Hispanics, and whites in the US. Addictive Behaviors, 93, 158–165. https://doi.org/10.1016j.addbeh.2019.01.041

Morris, B. (2021). Sud treatment disparities. Research Gate. https://doi.org/10.13140/RG.2.2.26155.16163

Morris, B. (2023). Problem and solution landscape paper. [Unpublished manuscript. Suzanne Dworak-Peck School of Social Work, The University of Southern California].

Panchal, N. (2023). Five key findings on mental health and substance use disorders by race/ethnicity. KFF. https://www.kff.org/mental-health/issue-brief/five-key-findings-on-mental-health-and-substance-use-disorders-by-race-ethnicity/ 

Prison Policy Initiative. (n.d.). Race and ethnicity. Prison Policy Initiative. Retrieved October 4, 2022, from https://www.prisonpolicy.org/research/race_and_ethnicity

Saloner, B., & Cook, B. (2013). Blacks and Hispanics are less likely than whites to complete addiction treatment, largely due to socioeconomic factors. Health Affairs, 32(1), 135–145. https://doi.org/10.1377/hlthaff.2011.0983

Stein, B. D., Celedonia, K. L., Swartz, H. A., Burns, R. M., Sorbero, M. J., Brindley, R. A., & Frank, E. (2015). Psychosocial treatment of bipolar disorder: Clinician knowledge, com- mon approaches, and barriers to effective treatment. Psychiatric Services, 66(12), 1361–1364. https://doi.org/10.1176/appi.ps.201400004

Suntai, Z., Lee, L., & Leeper, D. (2020). Racial disparities in substance use treatment completion among older adults. Innovation in Aging, 4(6), 51. https://doi.org/10.1093/geroni/igaa051 

Whelan, A. (2020, May 27). Even with private insurance, black overdose patients are half a likely as whites to get addiction treatment, Penn Study finds. Inquirer. https://www.inquirer.com/news/racial-disparities-ad-diction-treatment-private-insurance-opioid-crisis-20200527.html

Yale School of Medicine. (2021, October 1). Racial inequities in treatments of addictive disorders. https://medicine.yale.edu/news-article/racial-inequities-in-treatments-of-addictive-disorders/