Key Results: Racial and Ethnic Disparities in Substance Abuse Treatment
Citations Listed in Key Results
- The need for substance abuse services differs significantly across racial and ethnic groups.
Alcohol- and drug-related consumption, problems, illnesses (morbidity) and mortality are different across racial and ethnic groups in the country. For a given level of alcohol consumption, African Americans and Hispanics experience an overall greater risk of related problems (Caetano and Clark, 1998a; Herd, 1994), such as cirrhosis (Greenfield, 2001) and higher alcohol-related mortality rates (Caetano, 2003; Montoya, 2001; Stinson et al., 1993; Yoon et al., 2001). African Americans and Hispanics are also disproportionately affected by drug-related problems.
A review of research on racial/ethnic differences in drug use and its consequences found that African Americans are more likely than Caucasians to be dependent upon marijuana and cocaine, and African Americans and Hispanics have been shown to have higher rates of fatal drug overdose and higher age-adjusted AIDS mortality rates and HIV seroprevalence compared to Caucasians (Galea and Rudenstein, (2005).
The persistence of substance use problems also varies by racial and ethnic group. There is evidence that African American and Hispanic men have longer heavy-drinking "careers" and more stable rates of alcohol-related problems compared to white men (Caetano and Kaskutas 1995; 1996). This is consistent with the findings of a recent National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) analysis showing lower remission of alcohol dependence among African Americans, Hispanics and other minorities compared to Caucasians (Dawson et al., 2005).
In addition, the gap in the need for treatment services has grown over time. National surveys have documented a general decline in alcohol consumption and problems among Caucasians that began in the mid-1980s. But during the same time period, levels of consumption and problems have remained stable or increased in the largest minority groups: African Americans and Hispanics. Increasing rates of alcohol problems among Hispanic men are particularly striking. Between 1984 and 1995, rates of three or more symptoms of alcohol dependence grew in this group from 9 to 16 percent (Caetano and Clark (1998b).
National trends also show evidence of increased drug problems among some racial and ethnic minority groups, specifically in relation to marijuana use. From 1991 to 1992 and from 2001 to 2002, the prevalence of marijuana abuse and dependence in young African American and Hispanic men more than doubled to 6.1 and 4.7 percent respectively, and in young African American women the rate increased from 0.7 to 3.2 percent (Compton et al., 2004). During this same period, rates did not increase among young Caucasian men and women.
Most studies only compare Caucasians, African Americans and Hispanics and are largely exclusive of Native Americans and Asians/Pacific Islanders, thus neglecting the wide variation in cultures and national origin within these large population groupings. There is as well significant variation among Hispanics from differing countries of origin. Where adequate samples are available, national surveys indicate that Native American men and women have had the highest rates of clinically significant alcohol and drug problems in the last decade (Grant et al., 2004; Smith et al., 2006).
- The co-existence of substance abuse problems with psychiatric problems varies by racial and ethnic groups, suggesting different needs with respects to recovery support services.
The co-existence or "co-occurrence" of alcohol, drug and psychiatric problems is fairly common. Twenty percent of persons with substance use disorders also manifest a mood or anxiety disorder, and as many as 48 percent of people with drug disorders also have a personality disorder (Grant et al., 2004a; Grant et al., 2004b).
Research shows that rates of co-occurring disorders can vary by racial and ethnic group in America. For instance, co-occurring alcohol disorders and drug dependence, particularly cocaine addiction, appear to be more common in African Americans and Hispanics compared to Caucasians (Caetano, 2003; Hesselbrock et al., 2003; Morgenstern and Bux, 2003). Amongst those who are dependent on alcohol, major depression appears more prevalent among non-African Americans as compared to African Americans (Grant and Harford, 1995). And according to NESARC data, co-occurring mood disorders are more likely to affect Native Americans and African Americans with substance use disorders as compared to their Caucasian counterparts (Huang et al., 2006). This same study found that Hispanics were more likely than Caucasians to have co-occurring drug use and personality disorders.
- There are racial and ethnic disparities in access to substance abuse services.
The substance abuse "treatment gap" represents those members of a racial and ethnic group who are currently in need of alcohol and drug treatment but have not received care in the past year. National results suggest that the group representing the largest proportion of Americans with an unmet need for substance abuse services is Native Americans, including Alaska Natives. With the exception of Asian Americans, all racial and ethnic groups with substance dependence have a larger treatment gap than Caucasians. Ironically, many population-based studies exclude Native Americans and Alaska Natives due to their smaller numbers. Yet these are the very population groups with some of the greatest unmet treatment needs.
Racial and ethnic disparities in access to care also occur across types of substance abuse services. Hispanics, for example, are under-represented in most kinds of addiction treatment programs except for drinking-driving programs (Schmidt and Weisner, 1993; Weisner and Schmidt, 1993). On the other hand, African Americans are over-represented in public substance abuse programs as compared to their numbers in the general population, even after controlling for socioeconomic status (Weisner and Schmidt, 1994).
This difference may occur because public substance abuse programs are linked to courts and African Americans, when they do receive treatment, are more likely to enter care through legal and court channels (Polcin and Beattie, 2007). This finding may also reflect the large racial/ethnic differences in incarceration rates. Interestingly, a national study showed that, among parents involved with the child welfare system, there were no significant racial and ethnic differences in the utilization of substance abuse treatment (Libby et al., 2007).
Racial and ethnic differences have also been found in access to ancillary or supplemental treatment services, such as legal and employment counseling. In a study of male methadone patients that controlled for treatment need and duration, African Americans and Hispanics were half as likely as Caucasians to utilize any supplemental services (Wu et al., 2004). Similarly, research has shown that despite their greater need for ancillary services, African American and Hispanic drug offenders don't receive them any more often than Caucasian offenders do and sometimes are less likely to get such care (Fosados et al., 2007).
- Particularly large racial and ethnic disparities exist in getting appropriate care for a substance abuse problem.
The appropriateness of services refers to the degree to which care is matched to the severity of need. The American Society of Addiction Medicine's (ASAM) Patient Placement Criteria, Second Edition-Revised (2001) recommends levels of care for substance abuse problems, taking into consideration both cost-effectiveness and clinical appropriateness (Mee-Lee and Shulman, 2003).
The ASAM criteria currently define the most broadly accepted, evidence-based standard of care for the treatment of substance use disorders (Center for Substance Abuse Treatment, 2006). ASAM placement criteria, for example, suggest that a person without physical dependence on alcohol or drugs (i.e., tolerance, withdrawal) should be assigned to a lower level of care - such as a lower-intensity outpatient program - in the interests of efficiency and providing the least restrictive treatment setting. In contrast, a person with a clear physical dependence on alcohol or drugs and a co-occurring psychiatric disorder should receive multiple types of services and a higher level of specialty care (e.g., detoxification followed by intensive outpatient treatment and psychiatric monitoring) (Rasmussen, 2000).
There is evidence that the nature of services provided to American racial and ethnic minority groups may not be appropriate to their severity of need (Greenfield, 2001; Harwood et al., 2001; National Institute on Alcohol Abuse and Alcoholism, 2001; Schmidt et al., 2007). Several ethnic minority groups with dependence (as compared to those with abuse) have greater unmet need, including Native Americans, Pacific Islanders and African Americans (Schmidt, Tam and Larson, 2007).
One recent study by Schmidt and colleagues (2007) found that when alcohol problems were less severe, Hispanics, African Americans and Caucasians had similar treatment rates, yet as the severity increased, Hispanics and African Americans were less likely to receive treatment services than their white counterparts. Hispanics were also less likely to obtain specialty treatment and multiple types of services even though their alcohol problems were more severe (Bluthenthal et al., 2007). This may be explained, in part, by differences across ethnic groups in financial and other barriers to care (Grant, 1997; McAuliffe and Dunn, 2004; Schmidt et al., 2007).
- Barriers to care differ across racial and ethnic groups in America.
Policymakers and public health officials have a particular interest in how policy changes, such as increasing the availability of treatment slots where they are most needed, can affect different factors that influence someone to seek help.
Inter-state comparisons of the supply of alcohol and drug treatment programs by McAuliffe and Dunn (2004) show that America's most underserved areas are those in the southern and southwestern regions - areas with disproportionately large minority populations. National survey data further indicate that African Americans are more likely than non-African Americans to cite long waiting lists as an obstacle to substance abuse treatment (Grant, 1997). For Hispanics, access to care is additionally constrained by language barriers (Blondell et al., 2006; Doty, 2003). This latter finding is corroborated by regional comparisons showing greater treatment utilization in ethnically diverse communities that have more bilingual and bicultural treatment providers (Rouse et al., 1995).
There are racial and ethnic differences in the fear of stigma and negative attitudes among those who seek help for substance abuse. In an analysis of barriers to treatment, Grant (1997) found that non-African Americans, compared to African Americans, had a less favorable orientation to seeking treatment for alcohol problems and a greater fear of being stigmatized by going to treatment.
Despite this, other studies suggest that experiences with discrimination and stigma may still act as barriers to treatment among ethnic minorities. Recent work has shown that racial bias and discrimination can lead to adverse health effects (Williams et al., 2003), as well as substance use and problems (Gibbons et al., 2004; Martin et al., 2003; Mulia et al., 2008; Yen et al., 1999). Some studies have found that substance users are acutely aware of negative stereotyping and disrespect by health care providers, including substance abuse service providers (Mulia, 2002; Neale, 1998; Nelson-Zlupko et al., 1996).
Logistical barriers to treatment can disproportionately affect access to care for ethnic minorities. African Americans and Hispanics are more likely than Caucasians to cite lack of childcare as an obstacle to treatment. Hispanics are also more likely to report difficulties with locating and paying for treatment services as reasons for not using treatment (Grant, 1997; Schmidt et al., 2007).
- There are racial and ethnic differences in economic factors that can facilitate entry into substance abuse treatment, such as health insurance coverage, but they don't completely explain treatment disparities.
There are significant racial and ethnic disparities in insurance coverage among Americans with addiction problems. An analysis of the National Alcohol Survey found that 28 percent of African Americans and 41 percent of Hispanics with a current substance dependence diagnosis were uninsured, compared to 19 percent of Caucasians and others with a dependence diagnosis (Schmidt et al., 2006).
Substance abuse treatment is, however, heavily subsidized through federal block grant funding and Medicaid, which may explain why insurance coverage does not predict treatment access very well (Schmidt and Weisner, 2005). It may be the case that private insurance coverage has greater impact on access to non-specialty alcohol and drug treatment services, such as care from medical or psychiatric settings (Schmidt and Weisner, 2005).
But even when differences in insurance and health coverage are taken into account, minorities are still less likely to access treatment. In a national analysis of uninsured persons with substance abuse problems by Wu and colleagues (2003), Caucasians were three times more likely to receive substance abuse treatment than African Americans. Similarly, a study of substance abuse treatment quality among Massachusetts Medicaid clients found that even with the same managed behavioral health care provider, African Americans and Hispanics with substance abuse disorders were still less likely than Caucasians to obtain treatment services and to have continuing care services (Daley, 2005).
- There are racial and ethnic differences in the pressure exerted on people with substance abuse to seek treatment.
One of the major pathways to substance abuse treatment is through pressure by family, friends, employers and legal authorities (Weisner, 1990). Evidence suggests that such pressure is more intense in some minority communities, such as among African Americans (Herd, 1988).
Moreover, larger proportions of minorities than Caucasians are committed to treatment through legal coercion, and at similar levels of alcohol or drug use African Americans and Hispanics are more likely than Caucasians to be arrested for a drug-related offense (Polcin and Beattie, 2007). In a revealing analysis, Chasnoff and colleagues (Chasnoff et al., 1990) examined rates of compulsory treatment referral among pregnant women in Florida. Toxicological tests showed that there were no racial or ethnic differences in the actual use of alcohol and drugs among these women. Even so, African-American women were ten times more likely than Caucasian women to be reported to the authorities for court intervention and compulsory treatment.
- The quality of available substance abuse services may vary across racial and ethnic groups in America.
There are good reasons to suspect that racial and ethnic disparities in the quality of alcohol and drug services are ubiquitous. Typically, the quality of substance abuse treatment is equated with high rates of treatment engagement and retention (Garnick et al., in press). However, multiple studies found that these engagement and retention rates are generally lower for ethnic minorities (McLellan et al., 2003; Mertens and Weisner, 2000; Tonigan, 2003).
For instance, a study of public substance abuse treatment programs in Los Angeles found that African Americans were roughly half as likely as Caucasians to complete outpatient and residential alcohol treatment (Jacobson et al., 2007). Interestingly, there is also evidence that racial differences in treatment completion would be reduced if African Americans in outpatient programs were to have the same probability of receiving residential treatment as Caucasians with similar characteristics (Bluthenthal et al., 2007).
Another standard indicator of quality in alcohol and drug treatment is "waiting time," or the time it takes a person on a waiting list for an alcohol and drug program to actually begin treatment. As noted, data from national surveys find that African Americans are more apt to report that they have failed to attend treatment because they were placed on a waiting list for too long.
Patient satisfaction also may be a revealing measure of the quality of care. An analysis of the multi-site clinical trial Project MATCH found that African Americans and Hispanics reported significantly lower satisfaction with alcohol and drug treatment relative to Caucasians, and this is supported by research showing differences in treatment retention (Tonigan, 2003; Bluthenthal et al., 2007). However, high minority client satisfaction has been reported in treatment programs attuned to cultural competence and diversity (Bernstein et al., 2005).
- Evidence from clinical trials suggests similar treatment outcomes between different racial and ethnic groups.
Alcohol and drug treatment has been widely shown to reduce alcohol and drug problems (Institute of Medicine, 1990; Miller et al., 2001; Moos et al., 1990), and in particular, to facilitate abstinent recovery (Dawson et al., 2005; Mojtabai, 2005; Vaillant, 2003; Weisner et al., 2003).
Findings from clinical trials suggest that minorities and Caucasians may have similar treatment outcomes despite the less favorable prognostic conditions of minorities when they enter treatment (Schmidt et al., 2006). For example, minorities may enter alcohol treatment with lower incomes, less education, more legal and employment problems, more extensive family histories of alcohol and drug addiction, more co-occurring drug abuse and poorer physical health (Brower and Carey, 2003; Le Fauve et al., 2003). It remains to be seen whether this reflects racial/ethnic differences in the types of individuals who enter care or in the strengths and coping mechanisms that individuals bring to the treatment process.
The multi-site clinical trial Project MATCH, which examined the impact of outpatient and aftercare services, noted that African American and Hispanic 12-month drinking outcomes were comparable to, if not better than, those of Caucasians (Tonigan et al., 2003). This was somewhat surprising, given that African Americans reported more drinks per drinking day at baseline, and Caucasians, by comparison, were more educated and showed greater readiness to change.
Another randomized study examined differences in continuing care outcomes among African American and white alcohol- and cocaine-dependent patients. It found many baseline differences at entry to continuing care, including, among African Americans, more severe socioeconomic problems, and higher rates of past and current cocaine dependence and cohabitation with an alcoholic. Despite these factors, alcohol and cocaine outcomes did not significantly differ between Caucasians and African Americans (McKay et al., 2003).
Results from clinical trials comparing minorities and others need to be interpreted with caution. The finding of no differences between ethnic groups despite differences in treatment prognosticators could result from unidentified strengths and coping mechanisms that minorities bring to treatment. Alternatively, study findings may be biased by the fact that minority patients have a higher probability of being excluded from efficacy trials. Minority patients disproportionately have characteristics that are often among the criteria mandating exclusion from a trial, such as psychiatric problems, heavy drug use and homelessness (Humphreys and Weisner, 2000). The results from clinical trials of treatment efficacy may therefore not apply to the general population (Lowman and Le Fauve, 2003).
Consistent with this argument, other studies have found mixed results regarding ethnic differences in treatment outcomes (e.g., see Fosados et al., 2007; Howard et al., 1996; Pelissier et al., 2001; Rosenheck and Seibyl, 1998; Rounds-Bryant et al., 2004). Lower rates of treatment engagement and retention among minority patients could similarly bias results, for example, by leaving only the most motivated minority patients in the study. Finally, standard racial and ethnic designations mask considerable differences that exist within ethnic and cultural groups. Thus, a finding of no differences in treatment outcomes could be related to the use of overly broad racial and ethnic categories.
- Research to date has provided little evidence that culturally appropriate treatments for substance abuse are more clinically effective, but some type of specialization may have a role to play in reducing treatment disparities.
According to the national treatment program data collected by the Substance Abuse and Mental Health Services Administration (SAMHSA) about one-third of substance abuse treatment programs nationally offer specialty services for African Americans and Latinos, and less than one-fifth offer specialized services for Native Americans. Those who favor specialization believe such programs are not only more effective, but also better able to engage and retain minority clients (Petry, 2003).
In support of this view, there is some evidence that communities offering more services with bilingual and bicultural staff have higher utilization rates among minorities (Rouse et al., 1995). Therefore, even if culturally appropriate programs do not improve outcomes, they may increase client satisfaction and providers' ability to engage and retain minority clients in treatment.
Treatment outcome researchers have also investigated claims that culturally-specific treatment programs, as well as therapist-client matching on race, are more effective for minority patients than standard treatment regimens. So far, these studies have provided very little support for the idea that specialized treatment protocols produce superior clinical outcomes (Institute of Medicine, 1990; Tonigan, 2003). However, there has not been, as yet, a randomized controlled trial using a culturally-specific treatment regimen guided by manuals. This type of study would provide the strongest evidence for or against the effectiveness of such an approach (Tonigan, 2001).
There is growing evidence from clinical trials that pathways to recovery from alcohol and drug problems may differ across racial and ethnic groups, raising the provocative idea that more effective treatment regimens could be developed on the basis of such evidence (Le Fauve et al., 2003). These studies also document that racial and ethnic groups sometimes differ in their responses to standard treatment approaches. Thus, Native American patients in Project MATCH experienced better outcomes from motivational enhancement therapy than from cognitive behavioral therapy or 12-step facilitation (Villanueva et al., 2002). For example, there may be further differences within important minority subpopulations - such as those defined by age or co-occurring disorders - but as yet, there is very limited research on these groups (for an exception, see: Venner et al., 2003).