Mark Sanders, LCSW, CADC, sees ominous signs in the few addiction professionals of color returning to school to pursue advanced degrees in clinical practice.
André Johnson copes with the effects of slashed local funding support for recovery support services in the Detroit metro area.
Pooja Lagisetty, MD, speculates as to why her research team found wide disparities in African-Americans' access to an evidence-based treatment for opioid use disorder (OUD).
Those who study or work on the front lines of addiction treatment for African-American populations consistently try to elevate the discussion of racial disparities in service, as the nation's attention continues to focus on an opioid crisis that has largely been portrayed as a white suburban phenomenon.
“This [disparity] has been with us for a long time,” Sanders, a Chicago-based behavioral health trainer and consultant and a faculty member at Governors State University, tells Addiction Professional. “In many settings I still see a lot of people receiving segregated services.”
And when he speaks before audiences of professionals at meetings that address the latest advances in treatment, Sanders reports seeing too little representation among programs run by African-American directors in metropolitan areas.
“They need to see how important it is to make sure their team gets sent to events,” Sanders says of these leaders. He adds, however, that the relative absence of minorities on conference planning committees and in promotional materials will often send a less than welcoming message to the professionals who work in these facilities.
Stark findings of study
The issue of racial disparities in access to high-quality treatment was highlighted last spring with publication of a research letter in JAMA Psychiatry, indicating that far fewer African-Americans than whites receive buprenorphine treatment for OUD despite a comparable need for care in the two populations.
The study examined patient visits resulting in a buprenorphine prescription between 2012 and 2015, with the research motivated largely by a relative lack of study of buprenorphine treatment trends compared to those for the more highly regulated methadone, co-author Pooja Lagisetty, a health services researcher in the Division of General Medicine at the University of Michigan School of Medicine, tells Addiction Professional.
National surveys have shown a roughly equal prevalence of OUD in the white and African-American populations, Lagisetty says (just under 5% for whites, around 3.5% for African-Americans). However, this study found that even after controlling for factors potentially affecting access to care, including a patient's insurance status, white patients were three to four times more likely than African-American patients to receive a buprenorphine prescription.
“The thing that is notable about this research is that while buprenorphine use in general since its authorization in [federal] DATA 2000 [legislation] has increased by a large amount, that increase is almost entirely limited to white individuals,” Lagisetty says.
This is not to say that African-Americans have been entirely shut out of evidence-based care for OUD, as research in locations such as New York City has demonstrated robust access to methadone treatment in the African-American population. However, the statistics regarding buprenorphine lead to speculation over whether a convenient office-based treatment alternative to clinic-based methadone has remained largely out of reach to many who could benefit from the option.
Lagisetty says the study, conducted along with researchers at the Veterans Affairs Ann Arbor Healthcare System, was not designed to identify the reasons why access to buprenorphine for African-Americans has been limited. Possible explanations include a relative lack of waivered prescribers in communities that mainly serve minority clients, a lack of awareness in these communities about the full range of potentially effective treatment options, and financial obstacles brought on by many buprenorphine practices moving to an exclusively self-pay structure.
“Our goal was just to highlight that there is a disparity,” Lagisetty says. “We hope this focuses the attention of policy-makers, researchers and physicians to dig deeper as to why this is happening.”
Some of the drivers of this may be subtle, she suggests. Without it ever being stated explicitly, she says, there seemed to have been a message delivered early on in the promotion of buprenorphine treatment that this breakthrough mainly represented a “suburban” alternative to methadone.
“We should be challenging ourselves to think beyond these categories,” Lagisetty says.
More resources needed everywhere
André Johnson is president and CEO of Detroit Recovery Project, a multi-service recovery center with a staff that includes 30 state-certified recovery coaches. A Detroit metro area population beset by poor socioeconomic conditions faces numerous challenges in accessing high-quality substance use services and supports, he tells Addiction Professional.
“In terms of primary treatment, we've had major financial changes in the system,” says Johnson, who in 2013 received the prestigious national Vernon Johnson Award from Faces & Voices of Recovery. “The number of days in treatment has been reduced significantly.”
This can be especially impactful for African-American patients, who in many cases may lack the community supports that are available to the middle-class individual who has been the face of the opioid crisis. Regardless, Johnson says it is important for community leaders to argue for more resources for treatment and recovery across the board, and for organizations to stop operating in silos that divide treatment from recovery and program from program.
“Let's not forget that we also have a cocaine epidemic. We have a marijuana epidemic,” asserts Johnson, whose many roles in the field also include serving as a trainer for the Great Lakes Addiction Technology Transfer Center (ATTC).
A greater influx of young talent is needed to work with complex patients, he says. “We need college kids with new ambition,” he says. “I don't care what color they are. But they need to be trained.”
Disparities run deep
Sanders makes reference to deep-seated notions about addiction in various groups, citing media accounts of how the substance-related problems of celebrities such as Judy Garland and Billie Holiday were historically viewed in diametrically opposite ways, even by the national government and law enforcement.
When the face of a drug crisis has been a person of color, as with crack cocaine in the 1980s and '90s, the response has tended to involve law enforcement and child welfare heavily, Sanders says. “The face of addiction today is suburban white youth,” he says, and this has helped to reinforce more of a disease concept nationally.
Treatment programs, Sanders believes, can play an important part in helping to level the playing field. They will be doing this with a workforce seemingly becoming less diverse, he adds. These are some of the questions program leaders should be asking themselves:
Are their facilities as welcoming as they could be? Do the pictures on the wall send a message?
Is the minority client's culture legitimately considered?
Is trauma sufficiently addressed, or is there a risk that patients are being retraumatized?
What happens when program rules are violated? Who stays and who goes?