Alexander Hubbell, MD
Brief Review - Racism in Addiction
This article originally appeared in the October 2020 Newsletter
Earlier this year, two publications were released highlighting racial bias in substance use patterns and substance use disorder (SUD) treatment, using both sociological and epidemiological approaches. Written by Sara Matsuzaka and Margaret Knapp, the article “Anti-racism and substance use treatment: Addiction does not discriminate, but do we?” is a comprehensive review of the difficulties faced every day by People of Color (POC) when navigating our addiction infrastructure. Their summary quote stands alone: “Despite entering into substance use treatment with a greater severity of SUD and related consequences, POC experience more barriers to treatment engagement, completion, and satisfaction than their White counterparts.”
SAMHSA backs up this claim in their recent release, The Opioid Crisis and The Black/African American Population: An Urgent Issue. Their introduction begins to spell out some of the inequities among the Black/African American community: “the rate of increase of Black/African American drug overdose deaths between 2015-2016 was 40 percent compared to the overall population increase at 21 percent”. They dive into the state-level inequities as well; for instance “of DC’s opioid-related overdose deaths, 89 percent were among non-Hispanic Blacks”. The data present a balanced look at the demographics of substance use and overdose, highlighting inequities while appropriately noting the data as a whole.
Please note: In this review, I use the term “Blacks” or “POC” in reference to Matsuzaka and Knapp’s use of these terms, and the term “Black/African American” as used by SAMHSA. Important terms are defined in these papers, including the important idea of antiracism, which can be further explored in the bestselling novel How to be an Antiracist by Ibram X. Kendi.
According to SAMHSA’s national survey, Black individuals have similar overall substance use rates compared to other races, but overdose rates are increasing faster than all other studied racial groups. This is particularly alarming when rates of synthetic opioid (fentanyl) overdose are analyzed - see Figure 1 below. SAMHSA explains this in part by discussing a history of under-prescribing of opioids for pain among Black patients, who have historically experienced “misperceptions and biases in the healthcare system including the undervaluing of Black/African Americans’ self-reports of pain and stereotyping by providers.” Once a SUD has been established, Black patients enter into treatment with higher severity of disease and face more barriers to engaging in treatment, according to work by Matsuzaka and Knapp. This disparate entry into addiction treatment is primarily driven by economic barriers - disproportionately low employment rates lead to fewer privately-insured individuals and restricted access to “quality substance use treatment services”. Further, chronic poverty and “environmental violence” add to decreased engagement and retention.
SAMHSA addresses stigma with a combination of evidence and community voices, while Matsuzaka and Knapp delve into these details with well-sourced nuance. They weave a narrative of increased psychological distress, worsened by racial discrimination, leading to substance misuse. Contributing factors include the under-current of implicit bias and systemic racism, media depictions of POC developing SUD based on morality instead of contextual influences, intergenerational substance use especially among impoverished individuals, and a lack of culturally responsive approaches. They separately lamented the perception of addiction as a “weakness” or a “moral failing” instead of a disease.
Beyond these factors looms the specter of the criminal justice system. Blacks represent 80% of individuals sentenced under federal crack cocaine laws despite comparable rates of use among racial groups. Black women routinely lose custody of their children when they seek help for their disease. Though further study has been done on this topic and there is plenty more to say, these articles only touch briefly on the subject.
Once patients overcome these barriers to entry, they continue to face unequal opportunities for success. SAMHSA shows that Black/African Americans are more likely to have access to methadone than buprenorphine in their communities; this association also holds up with economic status, whereby low-income individuals faced similar choices. However, as one key informant states, “[you] can’t just drop bupe into a clinic - the tenor of outreach and community relations is critical”. Both papers highlight the “whitewashing” of prevention campaigns and show how messaging ignores the experience of Black individuals. This carries over to treatment settings, where there is a dearth of culturally responsive care. Matsuzaka and Knapp advocate for an anti-racist approach that includes “the development of racial consciousness, a reduction in racial microaggressions, and the adoption of a non-color- blind approach.” Both papers provide specific examples of how to implement change in treatment centers and communities to overcome the present bias.
These articles provide both an understanding of a deeply complex issue and opportunities for growth, many of which are immediately attainable within our own personal practices. Matsuzaka and Knapp address providers directly, urging us to advocate for improved trainings and policies that support an antiracist approach to addiction medicine. Those of us who work in treatment centers are also provided a roadmap for change, and all of us can influence our communities by promoting the types of programs extensively detailed in SAMHSA's review. No matter how we approach the subject, more reading and more conversation needs to happen in order to fully recognize the stigma in ourselves and our communities.
Brief Review - Racism in Addiction
This article originally appeared in the October 2020 Newsletter
Earlier this year, two publications were released highlighting racial bias in substance use patterns and substance use disorder (SUD) treatment, using both sociological and epidemiological approaches. Written by Sara Matsuzaka and Margaret Knapp, the article “Anti-racism and substance use treatment: Addiction does not discriminate, but do we?” is a comprehensive review of the difficulties faced every day by People of Color (POC) when navigating our addiction infrastructure. Their summary quote stands alone: “Despite entering into substance use treatment with a greater severity of SUD and related consequences, POC experience more barriers to treatment engagement, completion, and satisfaction than their White counterparts.”
SAMHSA backs up this claim in their recent release, The Opioid Crisis and The Black/African American Population: An Urgent Issue. Their introduction begins to spell out some of the inequities among the Black/African American community: “the rate of increase of Black/African American drug overdose deaths between 2015-2016 was 40 percent compared to the overall population increase at 21 percent”. They dive into the state-level inequities as well; for instance “of DC’s opioid-related overdose deaths, 89 percent were among non-Hispanic Blacks”. The data present a balanced look at the demographics of substance use and overdose, highlighting inequities while appropriately noting the data as a whole.
Please note: In this review, I use the term “Blacks” or “POC” in reference to Matsuzaka and Knapp’s use of these terms, and the term “Black/African American” as used by SAMHSA. Important terms are defined in these papers, including the important idea of antiracism, which can be further explored in the bestselling novel How to be an Antiracist by Ibram X. Kendi.
According to SAMHSA’s national survey, Black individuals have similar overall substance use rates compared to other races, but overdose rates are increasing faster than all other studied racial groups. This is particularly alarming when rates of synthetic opioid (fentanyl) overdose are analyzed - see Figure 1 below. SAMHSA explains this in part by discussing a history of under-prescribing of opioids for pain among Black patients, who have historically experienced “misperceptions and biases in the healthcare system including the undervaluing of Black/African Americans’ self-reports of pain and stereotyping by providers.” Once a SUD has been established, Black patients enter into treatment with higher severity of disease and face more barriers to engaging in treatment, according to work by Matsuzaka and Knapp. This disparate entry into addiction treatment is primarily driven by economic barriers - disproportionately low employment rates lead to fewer privately-insured individuals and restricted access to “quality substance use treatment services”. Further, chronic poverty and “environmental violence” add to decreased engagement and retention.
SAMHSA addresses stigma with a combination of evidence and community voices, while Matsuzaka and Knapp delve into these details with well-sourced nuance. They weave a narrative of increased psychological distress, worsened by racial discrimination, leading to substance misuse. Contributing factors include the under-current of implicit bias and systemic racism, media depictions of POC developing SUD based on morality instead of contextual influences, intergenerational substance use especially among impoverished individuals, and a lack of culturally responsive approaches. They separately lamented the perception of addiction as a “weakness” or a “moral failing” instead of a disease.
Beyond these factors looms the specter of the criminal justice system. Blacks represent 80% of individuals sentenced under federal crack cocaine laws despite comparable rates of use among racial groups. Black women routinely lose custody of their children when they seek help for their disease. Though further study has been done on this topic and there is plenty more to say, these articles only touch briefly on the subject.
Once patients overcome these barriers to entry, they continue to face unequal opportunities for success. SAMHSA shows that Black/African Americans are more likely to have access to methadone than buprenorphine in their communities; this association also holds up with economic status, whereby low-income individuals faced similar choices. However, as one key informant states, “[you] can’t just drop bupe into a clinic - the tenor of outreach and community relations is critical”. Both papers highlight the “whitewashing” of prevention campaigns and show how messaging ignores the experience of Black individuals. This carries over to treatment settings, where there is a dearth of culturally responsive care. Matsuzaka and Knapp advocate for an anti-racist approach that includes “the development of racial consciousness, a reduction in racial microaggressions, and the adoption of a non-color- blind approach.” Both papers provide specific examples of how to implement change in treatment centers and communities to overcome the present bias.
These articles provide both an understanding of a deeply complex issue and opportunities for growth, many of which are immediately attainable within our own personal practices. Matsuzaka and Knapp address providers directly, urging us to advocate for improved trainings and policies that support an antiracist approach to addiction medicine. Those of us who work in treatment centers are also provided a roadmap for change, and all of us can influence our communities by promoting the types of programs extensively detailed in SAMHSA's review. No matter how we approach the subject, more reading and more conversation needs to happen in order to fully recognize the stigma in ourselves and our communities.