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August 13, 2015

Patients with substance use disorder aren't treated equally

Researchers at the Heller School's Institute for Behavioral Health (IBH) have published a new study that examines the inequitable healthcare treatment that certain racial/ethnic groups receive for substance use disorders. "Performance measures and racial/ethnic disparities in the treatment of substance use disorders," appears in the Journal of Studies on Alcohol and Drugs.

The research team examined whether there are racial/ethnic disparities in the treatment of substance use disorders in four states (Connecticut, New York, Oklahoma, Washington), focusing specifically on state-funded treatment services. They assessed disparities in “treatment engagement,” a marker of quality that focuses on the quantity and timeliness of services received early in treatment.

This study is part of a larger research project funded by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health conducted by a team of IBH researchers, including Deborah Garnick, Connie Horgan, Andrea Acevedo, Robert Dunigan, Margaret Lee, Lee Panas and Grant Ritter. Andrea Acevedo, PhD'12, the paper's lead author, talked with Heller Communications about the study’s key findings and contributions to the field of behavioral health research.

Andrea Acevedo

1. What are the most important findings from this study? Where any of them surprising to you?

We found that Black and American Indian clients are less likely than White clients to engage, or receive what is considered a minimal level of outpatient treatment services for substance use disorders. We tested whether socioeconomic differences may have driven those disparities, but that was not the case.

Although our previous work had shown that treatment engagement is associated with a reduction in post-treatment arrests, this is not the case for some groups in some of the states we examined. For example, in New York, engagement was not associated with a reduction in arrests for Latino or Black clients. This was also true for American Indian clients in Washington State.

The results are not surprising given that racial/ethnic disparities are well documented and pervasive in health services for several other conditions. Our work adds to a very limited literature on disparities in the treatment of substance use disorders. Perhaps a more surprising finding is that even when clients are receiving this minimal level of care, criminal justice outcomes differ by racial/ethnic group. There are other things outside of the treatment system that need to be considered.

It is important to note that disparities were not uniformly found across the four states we examined, and who was affected differed by state. This is probably due in part to differences in demographics, but probably also to differences in the treatment system and policies.

2. Why did you decide to focus on racial/ethnic disparities in substance use treatment, specifically? Why is this an important issue?

The impacts of substance use disorders on someone’s life are vast, including poorer health and higher risk of injury and mortality. The economic costs to the individual and society are also substantial--higher health care costs, loss of earnings and costs related to law enforcement. Not to mention other costs that cannot be quantified, such as emotional costs, including those of family members and friends concerned about the individual.

Yet, even when rates of substance use for some minority groups are similar to or lower than that of White individuals, the health, social and economic consequences of substance use are disproportionate for racial/ethnic minority groups. For example, according to the Centers for Disease Control, Blacks and Latinos make up over 70 percent of the estimated new HIV infections that are due to injection drug use. Also, the Black arrest rate for drug possession is approximately three times that of Whites, even though the Substance Abuse and Mental Health Administration reports that the estimated rate of illegal drug use for Blacks is only slightly higher than for Whites. There are already so many barriers for individuals to enter treatment. We are learning Blacks, Latinos, and American Indians are less likely to access treatment than Whites. Given the impact of substance use disorders and the barriers to care, it is critical that once treatment is accessed, that everyone receives equal care.

It is an issue of equity and fairness, and it also may help ameliorate some of the disproportionate consequences of substance use disorders that minority members experience.

For these reasons, we built in a focus on racial ethnic disparities when we wrote the proposal and the states that we partnered with–Connecticut, Oklahoma, New York and Washington–shared our eagerness to delve into this important issue.

3. What is the connection between inequities in substance use disorder treatment and inequities in the criminal justice system?

Overall, there is a strong connection between substance use disorders and the criminal justice system. Based on estimates from the Bureau of Justice Statistics, an estimated 13 percent of all arrests reported are for drug-related offenses, a third of state and a quarter of federal inmates report they committed their offenses under the influence of drugs, and almost 20 percent of state and federal prisoners report they were motivated to commit crimes to obtain money for drugs.

Often, treatment is a condition of probation or parole, and in the states where we had data, almost half of the clients had been referred to treatment by the criminal justice system.

Large inequities have been documented in law enforcement and the criminal justice system, particularly when it comes to drugs. According to the Bureau of Justice Statistics, Latinos and Blacks make up approximately 30 percent of the U.S. population, but they make up more than 60 percent of the prison population. As mentioned earlier, the arrest rate for drug possession is about three times that of Whites, even though the rate of illegal drug use for Blacks is similar to that of Whites. Other researchers have shown that non-White drivers are more likely to be searched after a traffic stop and that more racially heterogeneous neighborhoods are more heavily policed, disparities which could lead to differences in arrest rates for drugs.

4. How can practitioners and policymakers use this research to address the issue of racial disparities in substance use treatment?

First, racial/ethnic disparities need to be assessed. This can be done by stratifying quality indicators, like treatment engagement, separately by racial/ethnic group. Treatment providers may want to do this for their own treatment facilities. States, which will continue to play a key role in funding treatment services as more people become covered by Medicaid under health reform, may also want to do this for their state overall and for providers they have contracts with.

If disparities are detected, the causes of the disparities need to be understood. If there are inequities in care within a treatment facility, are all groups feeling welcome in the facility? Are some clients facing language barriers, and are treatment programs staffed to address these needs? Could there be provider bias? Or are there systemic inequities, such as a dearth of high quality treatment providers available in the neighborhoods where minorities live? The strategy to reduce or even eliminate disparities will depend on their source.

Additionally, there are disparities beyond the treatment system that impact people with substance use disorders that have to be addressed as well. This includes inequities in the criminal justice system, which could impact how well clients of color do after treatment.

5. Is there anything you'd like to add about this study, or the issue of health equity in substance use treatment?

Our work at the Institute for Behavioral Health on equitable treatment for substance use disorders continues. Building on the relationship we developed with our research partners in Washington State, we are currently exploring if the impact of financial incentives or support to treatment agencies through an alert system disproportionately affects different racial/ethnic groups.

I am leading a study exploring whether the characteristics of the communities where clients live may be associated with the inequalities we see in treatment processes and outcomes. It is important that we continue delving into issues of equity on an ongoing basis.

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This study was funded by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health Under Award # R01 AA017177 (PI: Garnick) and F31 AA018246 (PI: Acevedo). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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