Substance use disorders and treatment in Asian American and Pacific Islander Women: A Scoping Review

Abstract

Background and Objectives:

Asian American Pacific Islanders (AAPIs) face unique barriers in seeking treatment for substance use disorders (SUD) and are less likely than the general population to receive treatment. Barriers specific to AAPI women may be especially significant given identified gender and racial differences in SUD prevalence and treatment. This review examines rates of SUD in AAPI women and summarizes the literature on SUD treatment for AAPI women.

Methods:

Data from 2016–2019 NSDUH surveys were extracted to summarize rates of SUD. A scoping review of the literature on AAPI women and SUD treatment was conducted; eight articles published from 2010-present were reviewed.

Results:

The prevalence of SUDs among AAPI women increased overall, although rates of SUDs were generally lower in AAPI women compared to their male counterparts. Patterns of gender differences in SUDs varied for subpopulations of AAPI women. There is limited research on treatment utilization and access for AAPI women. The few studies that examined treatment outcomes found favorable outcomes for AAPI women; research on culturally adapted interventions was promising but nascent.

Discussion and Conclusions:

Literature on SUD treatment for AAPI women is limited. Availability of more culturally tailored treatments addressing the specific needs of AAPI women may lead to more acceptability and treatment utilization for this group. Additional research is needed to elucidate the unique barriers to treatment AAPI women face.

Scientific Significance:

With rising rates of substance use in AAPI women, there is a need to develop and test effective SUD treatments adapted for AAPI women.

Introduction

Asian American and Pacific Islanders (AAPIs) are a fast-growing, diverse population in the United States (US) who face unique barriers to seeking mental health and substance use treatment.¹ Rates of substance use disorder (SUD) in AAPIs are lower compared to the general population,² which often results in the exclusion of AAPIs from research studies.³ In the US, AAPIs represent over 50 distinct ethnicities, over 100 unique languages and dialects, broad ranges of socioeconomic status, nativity and immigration status, as well as geographic locations.⁴ However, AAPIs are often viewed as a homogenous group, which disregards the heterogeneity that exists not only between Asian Americans (AAs) and Native Hawaiian and other Pacific Islanders (NHOPIs) as broad categories, but also among the diverse subgroups that fall under these umbrella terms.

The “model minority” stereotype (MMS) has been applied to the AAPI community, particularly AAs, and frames Asian cultural beliefs and values as having led Asians to “success” in American society,⁵ a type of stereotype threat that may contribute to health and treatment disparities in the AAPI community.⁶ The MMS was first used during the American Civil Rights Movement to suggest that if other minority groups were to “follow” Asian Americans’ lead, they too could be successful in society,⁷ and contributes to the notion that AAPIs do not experience problems related to mental health and substance use.

The MMS is complex with relation to cultural adhesion and assimilation.⁸ Arguably, the MMS, at best, depicts AAPIs as successful, but still ultimately a minority, a caveat that paints AAPIs as being not truly “American.”⁹ However, there remains the perception that AAPIs have had success assimilating into “mainstream”/White culture, evidenced by frequently used measures of assimilation such as steady increases in socioeconomic status, high educational achievement, and residential integration and intermarriage with Whites.⁸ This has in part led to a perception that AAPIs are at low risk for SUDs.¹⁰ However, AAPIs in need of substance use treatment are less likely than persons of other racial/ethnic groups to receive treatment and are also less likely to recognize a need for treatment.¹¹ Of those in treatment, AAPIs are vastly underrepresented in treatment programs and are more likely to be discharged against medical advice.¹² This is of additional concern insofar as up to 50% of the AAPI population, particularly those of East Asian descent, are carriers of the ALDH2*2 polymorphism, a genetic mutation that results in inactivation of the enzyme aldehyde dehydrogenase, one of the enzymes in the liver that metabolizes alcohol.^13,14 Inactivation of aldehyde dehydrogenase results in the alcohol flushing response colloquially known as the “Asian flush/glow”.^14,15 The ALDH2*2 polymorphism that contributes to the flushing response has also been associated with many other health risks and complications. The ALDH2*2 polymorphism may alter certain health effects of alcohol, and potentially influences its carcinogenesis.¹³ The gene mutation may be related to many different cancers, including head and neck, esophageal and colorectal cancer, as well as cholangiocarcinoma.^13,15 Presence of the ALDH2*2 allele has also been linked to increased risk of esophageal cancer regardless of drinking behavior and is associated with increased risk of alcohol use-related complications, hepatocellular carcinoma from alcohol-related cirrhosis, lung adenocarcinoma, cardiovascular disease, osteoporosis, myocardial infarction, and poor breast cancer prognosis.^13,15,16

In addition to these longstanding concerns, since the start of the Covid-19 pandemic, AAPIs have reported an escalation in incidents of discrimination due to their racial background.¹⁷ One study found that 61% of AAPIs reported experiencing discrimination during the Covid-19 pandemic attributable to being an AAPI, although this varied widely among subgroups, with highest rates for Hmong (80%) and ethnic Chinese (65%) and lowest rates for Asian Indian (42%) and NHOPI (41%).¹⁸ Moreover, racial discrimination was reported more frequently by female participants in this study than male participants. Racial discrimination has been proven to be a major life stressor, and is associated with increased depression, suicidality, anxiety, substance use, and other psychological distress.^17,19 The recent spike in racially motivated attacks on the AAPI community during the Covid-19 pandemic raises concern of increased psychological distress and substance use among AAPI individuals.²⁰ AAPIs have reported increases in depressive symptoms during the pandemic compared to pre-pandemic, even when adjusted for other sociodemographic factors.²⁰ Experiencing incidents of racial discrimination and unfair treatment is associated with increased substance use and related consequences in AAPI populations.^19,21

AAPI women are a particular group with intersectional identities worth examining with regard to substance use and treatment needs, as both gender and racial differences in SUDs have been identified.^22,23 Evidence shows that women with SUDs are less likely than men to enter into SUD treatment, and face complex socio-cultural and socioeconomic factors that influence treatment seeking and related outcomes.²⁴ The “self-medication hypothesis” postulates some individuals with mental health challenges use substances to manage and/or avoid distressing feelings and emotional pain²⁵ and may be particularly salient for AAPI women. AAPI women may be more likely to self-medicate due to the strong stigma among some AAPI communities associated with seeking mental health care as well as lack of family communication about healthy coping mechanisms.²⁵ AAPI women may also self-medicate more than their non-AAPI peers because of different gender norms and gendered expectations from their family and culture. In particular, stress may be exacerbated for AAPI women due to acculturative efforts to adhere to feminine norms, which may be in conflict with gendered expectations of their culture of origin.²⁶ In spite of these vulnerabilities to substance use and the rising population of AAPI women in the US, few reviews have examined substance use treatment among AAPI women. To address this gap, we summarized data from the National Survey on Drug Use and Health (NSDUH) on rates of SUD in AAPI women and conducted a scoping review of the literature on AAPI women and substance use disorder treatment.

Methods

Examination of National Survey on Drug Use and Health Data

The Substance Abuse and Mental Health Data Archive (SAMHDA) Public-use Data Analysis System (PDAS) was used to extract data from the National Survey on Drug Use and Health (NSDUH) for the years 2016–2019.^27–30 Specifically, data were extracted from the NSDUH variables labeled “Imputation Revised Gender”, “Rc-Race/hispanicity Recode (7 Levels)”, and “Recoded Substance Dependence and Abuse”, defined by NSDUH using the DSM-IV definitions of substance dependence and abuse. Data extracted from this latter variable will be referred to as “substance use disorders” according to DSM-5 definitions, as the terms “dependence” and “abuse” are outdated. Recoded and revised variables were used according to NSDUH suggestion, as these variables have been edited to accommodate for missing data.³¹ Data from NSDUH are weighted because the estimates are based on sample survey data rather than on complete data for the population.³²

Scoping Review

Between June 2021 and April 2022, PubMed and PsycINFO databases were used to identify articles related to substance use treatment among AAPI adult women. Combinations of the following search terms were used to identify relevant articles: “women”, “female” “Asians”, “Native Hawaiian or Other Pacific Islander”, “drug use”, “drug users”, “drug user”, “Substance use”, “substance abuse”, “substance misuse”, “substance-related disorders”, “substance-related disorders”, “treatment,”, “racial minority,” “alcohol,” “cannabis,” “marijuana,” “smoking,” “tobacco,” “nicotine,” “opioid,” and “stimulant.” Additional studies were found by examining relevant reference lists. Two of the authors (CLW & MK) independently performed the literature searches and reviewed abstracts and articles for inclusion. Studies were excluded if the article (1) did not report data or results specific to substance use in AAPI adult women, (2) focused on substance use prevention programs, (3) described treatment programs or study protocols without any results, or 4) the study participants were under 18 years of age. Due to rapidly changing trends in substance use, as well as the demographic and cultural changes in the AAPI population in recent history,³³ only articles published from 2010 to present were included in this review. Although scoping reviews can include grey literature, we have limited our review to peer-reviewed articles. Forty articles met these criteria. We then further narrowed the literature to only articles that focused on treatment for SUDs, which resulted in 8 articles included in this review. For the included articles, data were extracted by two authors (CLW & MK) and a third author (DES) reviewed all articles and checked extracted data for accuracy. Figure 1 presents the PRISMA flow diagram of studies identified using our search strategy.

Figure 1.

PRISMA Diagram

Throughout this paper, the term ‘AAPI’ will be used to generally denote and describe the Asian American and Pacific Islander population when referencing studies that have not specified a focus on a particular subgroup of AAPI identity. For studies only examining Asian American populations that did not include Pacific Islander participants, the term “Asian American” (AA) will be used. For studies focused on Native Hawaiian/other Pacific Islander populations only, the abbreviation NHOPI will be used. In describing articles that have focused on certain AAPI subgroups, we will use the relevant specified language (i.e., Chinese American, Korean American, etc.). The terms “first generation,” “1.5 generation,” and “second generation” are used to describe AAPI’s generational status. First generation AAPIs are defined as having been born outside of the US; 1.5 generation is defined as having immigrated to the US before the age of 18. Second generation AAPIs are born in the US to foreign-born parents.

Results

Rates of Substance Use Disorders

Substance Use Disorder Trends for AAPI women 2016–2019.

Table 1 shows rates of SUD trends for AA and NHOPI women from 2016–2019.^27–30 The 2019 NSDUH data show AA women’s illicit (excluding marijuana) SUD rates and opioid use disorder (OUD) rates have increased since 2016. In 2019, AA women’s illicit SUD rate was nearly five-times that of 2016, and AA women’s OUD rates have doubled since 2016. Rates of stimulant disorder in AA women have tripled since 2016, while AA women’s cannabis use disorder rates have decreased since 2016. AA women’s alcohol use disorder (AUD) and tobacco use disorder have decreased from 2018–2019 after increasing from 2017–2018. With the exception of tobacco use disorder and OUD, NHOPI women’s SUD rates spiked in 2018, but then decreased from 2018–2019. NHOPI women’s illicit SUDs, AUD, cannabis use disorder, and stimulant use disorder rates all decreased from 2018–2019 after increasing from 2017–2018, while tobacco use disorder rates in NHOPI women has gradually decreased from 2016 to 2019, and NHOPI OUD rates have nearly tripled from 2018 to2019 after spiking from 2016 to 2017 and decreasing from 2017 to 2018.

Table 1.

Asian American and Native Hawaiian/other Pacific Islander (NHOPI) women’s substance use disorder rates (%) from 2016–2019.

	Asian American Women				NHOPI Women
	2016 (n = 7,624,168)	2017 (n = 8,000,303)	2018 (n = 8,173,739)	2019 (n = 8,491,121)	2016 (n = 684,022)	2017 (n = 557,438)	2018 (n = 478,392)	2019 (n = 466,299)
Illicit Drugs (excluding Marijuana)	0.15	0.16	0.62	0.71	0.65	1.99	3.89	1.76
Alcohol	2.61	1.79	3.37	2.37	0.69	2.71	9.72	2.32
Cannabis	1.86	0.80	0.66	0.81	1.52	0.28	6.47	0.67
Stimulants	0.07	0.00	0.13	0.21	0.19	0.00	1.99	0.00
Opioids	0.09	0.11	0.12	0.20	0.19	1.99	0.21	0.62
Tobacco *	1.65	0.42	1.00	0.71	7.68	6.91	6.64	4.71

Source: Substance Abuse and Mental Health Services Administration (SAMHSA)’s public online data analysis system (PDAS)

Survey: National Survey on Drug Use and Health, 2019, //pdas.samhsa.gov/#/survey/NSDUH-2019-DS0001/crosstab/?weight=ANALWT_C&run_chisq=false&results_received=true; National Survey on Drug Use and Health, 2018, https://pdas.samhsa.gov/#/survey/NSDUH-2018-DS0001; National Survey on Drug Use and Health, 2017, https://pdas.samhsa.gov/#/survey/NSDUH-2017-DS0001; National Survey on Drug Use and Health, 2016, https://pdas.samhsa.gov/#/survey/NSDUH-2016-DS0001

^*Based on Nicotine Dependence Syndrome Scale (NDSS) Score

Gender Differences in Substance Use Disorder Rates for AAPIs.

Table 2 shows a comparison of rates of SUDs in AA and NHOPI men and women for 2019.²⁷ Rates of AUD, cannabis use disorder, and tobacco use disorder are lower in AA and NHOPI women when compared to AA and NHOPI men respectively. For the categories “illicit substance use disorders excluding marijuana” and OUD, rates are higher in NHOPI women versus NHOPI men, while rates are lower in AA women compared to AA men. Notably, the rate of OUD in NHOPI women is nearly triple that of NHOPI men. Stimulant use disorder in NHOPI women and men is equivalent and low, but the rate of stimulant use disorder in AA women was more than five times that of AA men.

Table 2.

Comparison of rates (%) of substance use disorders in Asian American and Native Hawaiian/other Pacific Islander (NHOPI) men and women, 2019

	Asian American women (n = 8,491,121)	Asian American men (n = 7,400,000)	NHOPI women (n = 466,299)	NHOPI men (n = 600,910)
Illicit drugs (excluding marijuana)	0.71	0.90	1.76	1.63
Alcohol	2.37	4.03	2.32	7.53
Cannabis	0.81	0.97	0.67	2.62
Stimulants	0.21	0.04	0.00	0.00
Opioids	0.20	0.56	0.62	0.23
Tobacco *	0.71	1.27	4.71	4.89

Source: Substance Abuse and Mental Health Services Administration (SAMHSA)’s public online data analysis system (PDAS)

Survey: National Survey on Drug Use and Health, 2019, //pdas.samhsa.gov/#/survey/NSDUH-2019-DS0001/crosstab/?weight=ANALWT_C&run_chisq=false&results_received=true

^*Based on Nicotine Dependence Syndrome Scale (NDSS) Score

Racial/Ethnic Differences in Substance Use Disorder Rates in Women.

Table 3 shows a comparison of SUD rates in women by race and ethnicity for 2019.²⁷ AUD and cannabis use disorder rates are low for AA and NHOPI women compared to other racial groups of women. However, NHOPI women have the highest rates of illicit SUDs while AA women have the lowest rates. Similarly, OUD and tobacco use disorder rates are relatively higher in NHOPI women compared to other groups of women, and low in AA women compared to other groups. Conversely, rates of stimulant use disorder are high among AA women, but low among NHOPI women compared to other groups of women.

Table 3.

Rates (%) of substance use disorders in women, by race and ethnicity, 2019

	Asian American women (n = 8,491,121)	NHOPI women (n = 466,299)	Black/African American women (n = 17,987,113)	Native American/AK Native women (n = 837,466)	Hispanic women (n = 23,795,972)	Non-Hispanic White women (n = 97,346,919)
Illicit drugs (excluding marijuana)	0.71	1.76	1.22	1.55	0.93	1.39
Alcohol	2.37	2.32	3.68	3.60	2.94	4.25
Cannabis	0.81	0.67	1.68	2.53	1.57	1.05
Stimulants	0.21	0.00	0.11	0.09	0.07	0.24
Opioids	0.20	0.62	0.51	0.84	0.37	0.62
Tobacco *	0.71	4.71	4.59	9.01	1.90	7.39

Source: Substance Abuse and Mental Health Services Administration (SAMHSA)’s public online data analysis system (PDAS)

Survey: National Survey on Drug Use and Health, 2019, //pdas.samhsa.gov/#/survey/NSDUH-2019-DS0001/crosstab/?weight=ANALWT_C&run_chisq=false&results_received=true

^*Based on Nicotine Dependence Syndrome Scale (NDSS) Score

Scoping Review: Characteristics of Included Articles

Eight articles met our selection criteria and were grouped by relevant themes: Four on treatment access and utilization, two on treatment outcomes, and two on culturally tailored treatment programs. Table 4 provides descriptive information on included articles. Included articles were published from 2010–2020. Four articles reported on gender differences in AAPI samples, three contained samples that were mixed with respect to race and gender, and one study included AAPI women only. One study was a randomized controlled trial, one was a pilot study without a control group, and the rest were cross-sectional and secondary data analysis studies. Of note, three of the eight studies sampled participants from regions in California, two recruited participants from the Northeast, two used data from national databases, and one study was a multi-site survey study of participants in California and Arkansas.

Table 4.

Descriptive information of studies included in review

Citation	Substance(s)	Theme(s)	Sample Characteristics	Study Details	Results
Chen et al., 202035	Alcohol	Access to Treatment/Treatment Utilization	Mixed-Gender Racially diverse N=779,041 3% female 1% AAPI (4% female) 7% Hispanic 18% Black 1% American Indian/Alaska Native 73% White	Retrospective analysis of data extracted from VA’s National Corporate Data Warehouse, a repository of clinical, enrollment, financial, administrative, pharmacy, and utilization data on all VA patients Analysis restricted to data from outpatients who screened positive in a routine screening for unhealthy alcohol use (by AUDIT-C score) between 2009–2013	AAPI women had one of the lowest rates of receiving an alcohol brief intervention (68%), while AAPI men had one of the highest rates of receipt of a brief intervention (75%)
Satre et al., 20101	Alcohol and other drugs	Access to Treatment/Treatment Utilization	Mixed-Gender Racially diverse N = 22,543 52% female 17% Asian 63% non-Hispanic White 7% African American/Black 13% Latino	Cross-sectional survey data from a random sample of Kaiser Permanente Medical Care Program members in Northern California in 2002 and 2005. Analysis restricted to participants ages 20–65	AAPI women did not differ from other racial/ethnic groups or from men in receipt of SUD treatment AAPI women with depression were least likely to fill anti-depressant prescriptions compared to other racial/ethnic groups
Subica et al., 201936	Alcohol	Access to Treatment/Treatment Utilization	Mixed-Gender NHOPIs N=223 57% female 55% Samoan 45% Marshallese	Cross-sectional survey study of community-dwelling Samoans in Los Angeles and Marshallese in Northwest Arkansas, respectively.	Men had higher rates of AUD, but women are much more likely to report needing mental health services in the past year Women are also more likely to avoid or delay seeking out mental health services
Tong et al., 201134	Nicotine	Access to Treatment/Treatment Utilization	Mixed-Gender Chinese, Korean, and Vietnamese American smokers N = 6841 31% Chinese 37% Korean 32% Vietnamese	Secondary data analysis of combined data from California Tobacco Use Surveys for Chinese-Americans (2003), Korean Americans (2003), and Vietnamese-Americans (2007–2008); state-wide surveys sampled from telephone numbers belonging to individuals with Chinese, Korean, and Vietnamese surnames in California.	Participants who were older, female, Vietnamese American, or had health insurance were more likely to have seen a provider in the past year. No gender difference in receipt of provider advice to quit smoking
Garrison et al., 201938	Alcohol and Other Drugs	Treatment Outcomes	Mixed-Gender Racially diverse N=1,768,651 34% female 2% AAPI (29% female) 75% non-Hispanic White 22% Hispanic/Latinx	Retrospective analysis of pooled data from SAMHSA’s 2006–2011 Treatment Episode Data Sets-Discharge (TEDS-D) Analysis restricted to first-time admissions of outpatients not receiving medication assisted opioid therapy	AAPIs were more likely to complete SUD treatment when compared to other racial/ethnic groups AAPI women were more likely than White and Latinx women to complete SUD treatment; male completion percentages were similar across racial/ethnic groups
Han et al., 201637	Alcohol and other drugs	Treatment Outcomes	Mixed-Gender AAPIs N = 567 31% female	Secondary analysis of data from 2 multi-site prospective studies of treatment outcomes in 2000–2002 and 2004–2006 Analyses restricted to data from AAPI participants Treatment outcomes analyses restricted to 106 participants (33% female) with follow-up data	Women reported more significant improvements in substance use problems, but men reported more significant reductions in co-occurring psychiatric symptoms
Hahm et al., 201740	Alcohol and other drugs	Culturally Tailored Treatment	Female-Only AA 1.5 or 2nd generation women ages 18–35 N = 9 33% Chinese 44% Korean 11% Vietnamese 11% Multiethnic 78% US-born	Pilot non-controlled study of the Asian Women’s Action for Resilience and Empowerment (AWARE) intervention, a culturally informed group therapy designed for AA women to reduce depressive symptoms, suicidality, substance use, and HIV and sexual risk behaviors	Participants completed on average 8.7/10 sessions Qualitative analyses of participant feedback supported the acceptability and feasibility of AWARE and informed modifications of the intervention
Kim et al., 201539	Nicotine	Culturally Tailored Treatment	Mixed-Gender Korean immigrants N = 109 17% female Experimental group: n = 55 (16% female) Control group: n = 54 (17% female)	Randomized control trial of a smoking-cessation intervention adapted to incorporate Korean-specific cultural elements. Participants were recruited from the northeast regions of the US.	Experimental group showed higher rate of prolonged abstinence Women who achieved at least 3 months of prolonged abstinence had not relapsed at 6- and 12-month follow up

Access to Treatment and Treatment Utilization

Our search of the literature yielded four articles that reported information related to access to treatment or treatment utilization.^1,34–36 One study examined alcohol and other drugs,¹ two focused on alcohol only,^35,36 and one focused on nicotine.³⁴

In a secondary analysis of combined data from the California Tobacco Use Surveys of Chinese-, Korean-, and Vietnamese Americans who smoke, participants who reported having seen a health provider in the past year were more likely to be female. However, there were no differences by gender in participants who reported receiving advice from a provider to quit smoking.³⁴ No data were provided on the number of females in the sample or on their generational status.

Another study examined how the intersection of gender and racial/ethnic identity influences receipt of a brief intervention (BI) for unhealthy alcohol use.³⁵ In this study, data were extracted from the Veterans Affairs (VA) National Corporate Data Warehouse for patients who had received outpatient treatment and screened positive for unhealthy alcohol use between 2009–2013 (N=799,041). Overall, 71% of patients who screened positive for unhealthy alcohol use received a BI, but women who screened positive had lower rates of receiving a BI compared to men. Rates of receiving a BI also varied by race/ethnicity. Black women and Black men had the lowest rates of receiving a BI (66.8% and 68.1%, respectively) followed by AAPI women (68.4%). There was a particularly large difference between AAPI men and AAPI women, with AAPI men having one of the highest rates of receipt of BI (74.9%) and AAPI women having one of the lowest rates. However, AAPI women made up a very small percentage of the study population. Less than 2% of participants identified as AAPI, of which only 4% were female.³⁵

In an investigation of racial and ethnic disparities in access to treatment for depression and SUDs, Satre and colleagues¹ examined data collected from 2002–2005 through the Kaiser Permanente Adult Member Health Survey (N=22,543). Among all women with a diagnosed SUD, a co-occurring diagnosis of depression increased the odds of having initiated substance use treatment. However, compared to women in other racial/ethnic groups, AAPI women with depression were the least likely to have filled a prescription for an anti-depressant. AAPI women did not differ from other racial/ethnic groups or from men in receipt of SUD treatment. These results are limited, however, as the study had a very small sample of AAPI women with a diagnosed SUD (n=5).¹

Our search also yielded one study directly examining the unmet mental health needs of NHOPIs.³⁶ This multi-site study surveyed participants from both rural and urban settings. Analysis of survey data collected from 223 Samoan and Marshallese adults revealed that although men had higher rates of AUD, women were 4.4 times more likely to report needing mental health services in the past year, and 2.9 times more likely to report avoidance or delay in seeking out these services compared to men.³⁶ This analysis did not parse out substance use services from general “mental health” services, but these results help illustrate that AAPI women are seemingly less likely overall to seek out and receive mental health and substance use treatment. The reasons for this disparity in treatment seeking behaviors were not elucidated.

Treatment Outcomes

Our search yielded two articles reporting on SUD treatment outcomes data for the intersection of gender and AAPI identity.^37,38 In an analysis of data from SAMHSA’s Treatment Episode Data Sets-Discharge (TEDS-D) from 2006–2011, Garrison and colleagues³⁸ examined predictors of outpatient substance use treatment completion by racial/ethnic group. Results showed that compared to participants identifying as White, Latinx, and “other” racial/ethnic groups, AAPIs were significantly more likely to complete substance use treatment. In regard to gender, AAPI women were more likely to complete treatment when compared to White and Latinx women, whereas male completion percentages were similar regardless of racial/ethnic identity.³⁸ This study restricted analyses to patients receiving outpatient care and excluded individuals receiving medication treatment for opioid use disorder.

Han and colleagues³⁷ conducted a secondary analysis on 567 AAPI individuals in SUD community-based treatment from two multi-site prospective studies in California. For the purposes of this secondary analysis, the data from the two studies were combined, despite having different follow-up time points (9 months and 12 months). Neither study included a control group. Although most participants in these studies were receiving outpatient treatment, more women than men were in residential treatment centers; women were also more likely to report having never been in a controlled setting that restricted their potential access to substances, such as a detox program, hospital stay, or prison. Examination of changes in Addiction Severity Index composite scores between baseline and follow-up showed that women had more significant improvements in drug problems than men, although men exhibited significant reductions in symptoms of co-occurring psychiatric disorders while women did not. Treatment satisfaction was examined in a small subset of participants (n=58; 33% female). Compared to women, men reported greater satisfaction with their counselor’s empathy levels, as well as their counselor’s concurrence with them on treatment plans.³⁷

The results from these two studies are promising and illustrate that AAPI women may be more likely than their male counterparts to complete treatment and subsequently see improvements in their SUDs but may also be less likely to perceive empathy and report satisfaction with treatment. Further investigation into treatment outcomes of AAPI women in SUD treatment is necessary given the dearth of literature on this topic.

Culturally Tailored Treatments

We identified two studies exploring SUD treatments tailored for AAPI populations that reported results specific to AAPI women.^39,40 One study was an RCT involving Korean Americans who smoke³⁹, and one was a pilot study of an intervention targeting co-occurring substance use and trauma in AA women.⁴⁰

Kim and colleagues³⁹ examined a culturally adapted intervention for Korean Americans who smoke. The study targeted Korean-speaking immigrants and enrolled 109 participants (n=18 women). Participants in the experimental condition of this two-arm RCT received nicotine patches and weekly 40-minute counseling sessions incorporating Korean-specific cultural elements, while the control group received nicotine patches and counseling sessions that were not culturally adapted. Korean-culture specific elements included: contextualizing the harmful effects of carbon monoxide by relating it to a similar type of smoke poisoning widely recognized in Korea, presenting information on smoking-related cancer deaths of Korean celebrities, inviting family members into therapy sessions to coach them for assistance and support, utilizing Korean media in education, and training in behavioral skills to prepare for Korean-specific relapse situations, such as hosting a visitor from Korea who smokes, or visiting Korea. The interventions were delivered in the Korean language for all but one participant. Results showed that the experimental group had a higher rate of prolonged abstinence after eight weeks of treatment compared to the control group. There was also a gender difference in this outcome; after women had achieved 3 months of prolonged abstinence, none relapsed at subsequent follow-ups, while men continued to relapse even after 6 months of prolonged abstinence. These results should be interpreted with caution given the small number of women in the study.

A pilot non-controlled study (N=9) was conducted on the Asian Women’s Action for Resilience and Empowerment (AWARE) intervention, a culturally informed group therapy designed for AA women who have experienced intimate partner violence (IPV) and PTSD.⁴⁰ AWARE was developed for children of immigrants, and the pilot study recruited women of Chinese, Korean, and/or Vietnamese descent who were 1.5 and second generation. AWARE targets substance use, along with depressive symptoms, suicidality, and risk for sexually transmitted diseases; although, substance use was not a criterion for inclusion in the study. The intervention aims to be sensitive to trauma, family issues, and gender power dynamics by developing coping skills and encouraging free expression. It also includes a digital component in the form of daily text messages called AWARE stories. AWARE was designed with the aims of giving AA women an opportunity to openly discuss the sense of disempowerment that may have been learned from their family upbringing, perceived racism, and second-class citizenship, being an invisible minority in the US, and body image issues. Automatic self-hatred and thoughts of self-doubt that may result from comments made by family members and peers and unspoken expectations from Asian and American cultures were also addressed, as well as how these thoughts can develop into negative self-worth and contribute to depression and anxiety.

Of the nine women enrolled in the AWARE pilot study, four (44%) reported 5 or more alcohol drinking occasions in the past month, and only one participant reported marijuana use in the past month. On average, participants in the pilot study completed 8.7 sessions out of the 10 offered, and 6 out of the 9 participants attended all 10 sessions. Thematic analyses of qualitative data showed that participants appreciated the culturally informed components of AWARE, the acculturation alignment between participants and the therapist, coping skills related to emotional regulation, and being able to share their experiences in an all-female AA group. Based on participant feedback regarding suggested improvements, the authors made modifications to the intervention including making the technology more user-friendly to increase engagement outside of sessions, revising the sexual health sessions, and reducing the number of sessions from 10 to 8, but increasing the length of each session. Overall, data from this small pilot trial support the feasibility and acceptability of the AWARE intervention. However, outcome data related to substance use were not included in the published article.

Of note, in our search of the literature, we came across additional studies of the AWARE intervention.^41–43 Although AWARE is described as “a culturally informed group therapy intervention designed to reduce depressive symptoms, suicidality, substance use, and HIV and sexual risk behaviors among 1.5 and second generation AA young women with histories of interpersonal violence,”⁴⁴ (p.1538) these studies did not meet our inclusion criteria as they did not report any data related to substance use. These subsequent studies further support the feasibility of the AWARE intervention and also found that participation in AWARE was associated with reductions in depression, anxiety, and PTSD symptoms.^41,42 However, the effectiveness of AWARE in addressing AAPI women’s substance use remains unknown.

Discussion

This review outlines some emerging trends regarding AAPI women’s SUD rates, but further emphasizes that there are many gaps in the literature, particularly regarding treatment outcomes and availability of treatment that addresses the cultural factors that are important for AAPI women with SUDs. In addition, this literature is dominated by cross-sectional studies, highlighting a need for more prospective RCT studies examining substance use treatment outcomes in AAPI women.

Generally, rates of SUDs in 2019 were lower in AAPI women compared to their male counterparts. There were some exceptions, such that AA women had higher rates of stimulant use disorder than AA men, and NHOPI women had higher rates of OUD and SUDs compared to NHOPI men. Our review of the NSDUH data also showed noticeable differences in SUD rates and trends between AA and NHOPI women, with NHOPI women having higher rates of SUDs and tobacco use disorder than AA women. Moreover, in 2019, compared with women in other racial/ethnic groups, NHOPI women had the highest rates of illicit SUDs and AA women had the second highest rates of stimulant use disorder. These observed differences are noteworthy because AA and NHOPI individuals are often considered as a collective group of “AAPI”. However, grouping these populations together under the general “AAPI” term disregards the vast heterogeneity that exists not only between AAs and NHOPIs as broad categories, but also among the many different subgroups the terms encompass. Research on substance use in AAPI subpopulations supports this observed heterogeneity. In particular, studies have shown that Vietnamese women report the lowest rates of overall substance use compared to women of other AAPI identities.^45,46 Other studies have found that Korean American women, compared to women of other AAPI identities, were at higher risk for heavy and binge drinking.^47,48 These variations in reported substance use among different AAPI subpopulations highlight the limitation of examining SUDs in AAPI women under the broad scope of AAPI, as certain higher risk subgroups may be overlooked by the generalization of the AAPI umbrella term.

Our examination of the literature on SUD treatment utilization and access to treatment revealed mixed findings. Two studies did not find differences by gender or by racial/ethnic group in receipt of SUD-related services.^1,34 However, another study found a large disparity between AAPI men and women in receipt of a brief intervention for unhealthy alcohol use, with AAPI women having one of the lowest rates of receiving a brief intervention compared to other racial/ethnic groups.³⁵ In addition to differences in receipt of services, we found evidence that NHOPI women report a higher need for mental health services and more avoidance or delay in seeking those services compared to NHOPI men.³⁶ In the past, this has been attributed to an underestimation of the extent of problematic substance use in the AAPI community,³ but may also result from a lack of accessible treatment. AAPIs have been shown to perceive more barriers to mental health help-seeking than their White counterparts,⁴⁹ and practical and cultural barriers such as language differences and understanding and comfort with mental health and substance use care may be pervasive.³ However, with rising rates of SUDs in the female AAPI population, additional research is needed to further elucidate the unique barriers to treatment for AAPI women.

Despite evidence that AAPIs, particularly AAPI women, may be more hesitant toward seeking out substance use treatment, there is some evidence that AAPI individuals have similar, if not better, treatment retention rates compared to other racial groups.³⁸ However, there is a dearth of literature examining treatment outcomes for AAPI women. Our review of the literature revealed only two studies that examined treatment outcomes of AAPI women, results of which suggest that AAPI women may fare better in SUD treatment compared to AAPI men, as they were more likely to complete treatment and see more significant improvements in their SUDs, even though men reported being more satisfied with their treatment and perceiving greater empathy of their counselors.^37,38

Evidence suggests non-AAPI clinicians may have difficulty understanding the substance use characteristics and patterns of first-generation AAPI.⁵⁰ Therefore, having treatment providers who can deliver treatment in the patient’s preferred language, and are culturally sensitive and aware, may be helpful in making treatment more accessible and ensuring successful treatment.⁴⁰ However, there remains a lack of interventions adapted for AAPI women with SUDs. We found one RCT study that investigated a culturally-adapted intervention for AAPIs that reported data on women and this study was focused solely on smoking cessation among Korean Americans.³⁹ Importantly, this was a culturally specific and culturally responsive intervention that included providing the information in Korean with both male and female Korean bilingual providers. Results of this study were favorable for women in that women were more likely than men to maintain abstinence from cigarettes. However, the study included relatively few women. The only other study we found on a culturally-adapted intervention was a small pilot trial of the AWARE intervention.⁴⁰ Although substance use was addressed as part of the intervention, no data were reported on substance use outcomes.

In sum, the available literature on interventions culturally-adapted for AAPI women found that AAPI women preferred when treatment was contextualized to be more relevant to AAPI populations and favored programs that considered familial relationships and issues in treatment.^39,40 For example, acceptable culturally adapted interventions incorporated family members into treatment by inviting them into sessions to teach them skills to assist and support their family member in treatment.³⁹ Family relationships were also examined in the AWARE group therapy, and women in this study appreciated having an all-female group to freely discuss problems they may feel stem from familial conflicts.⁴⁰ Research with predominantly white populations also demonstrated preference in women with SUDs in receiving treatment in an all-female group responsive to their needs including those as parents and partners.^51,52 That said, the AWARE study is unique in examining AAPI women’s experiences in a group therapy that is tailored to intersectional identities of both gender and race/ethnicity. In addition, participants valued learning coping and emotional regulation skills, especially in dealing with family and peer pressures relating to body and self-image. Having a therapist of the same cultural background was also helpful in treatment, as women felt they could connect with their therapist on a more personal level and were able to open up about more difficult topics, such as gender dynamics and empowerment stemming from family structure, experiences of perceived and overt racial discrimination, and feeing like an “invisible minority” in the US.^39,40

As the literature is so limited, there are few patterns that can be identified from these results. However, these findings show relative promise for AAPI women seeking substance use treatment. They underscore the importance of addressing unique cultural issues experienced by AAPI groups, as well as co-occurring psychiatric disorders, which disproportionately affect women. Further research will be needed to advance our understanding of effective treatments and make more tailored treatment options accessible to this population.

Limitations

There are several limitations of this review. First, only a small number of studies met our inclusion criteria and most of the studies were cross-sectional in design, with limited research examining substance use outcomes in AAPI women. Second, the sample sizes of AAPI women in the included studies were very small. Increasing AAPI representation in research studies is important in understanding the experiences and needs of AAPI individuals as well as in allowing for statistical comparisons across gender and racial/ethnic groups. Third, recruitment of participants for most of the studies was limited to certain geographical areas (predominately California). Different regions often have different concentrations of AAPI subpopulations, as well as different rates of substance use, treatment access, and treatment utilization. Oversampling from one region may result in the exclusion of certain subpopulations and also limits generalizability of findings. Barriers to treatment for AAPI woman are also an important to understand in this population, however, we were unable to include a systematic review of this literature within the scope and limits of this manuscript.

There are additional limitations associated with the NSDUH data. First, the interviews are conducted only in English or Spanish. Therefore, AAPIs who do not speak English or Spanish, or have limited proficiency in these languages are not represented in the NSDUH data. Relying on family members for interpretation is problematic as cultural practices, shame, and stigma may reduce the likelihood of disclosing substance use.³ Second, the NSDUH data may be subject to response bias. Of the 148,023 addresses screened for the 2019 survey, 67,625 interviews were completed.²⁷ AAPIs with immigration concerns and fears of deportation may be less likely to participate in surveys and research, thus decreasing the representativeness of the sample. Third, although there are concerns that the stress and racial discrimination associated with the Covid-19 pandemic may have negatively affected AAPI women’s substance use, we were unable to include the NSDUH 2020 data as the Covid-19 pandemic led to methodological changes in data collection and the Substance Abuse and Mental Health Services Administration cautions against comparing these data to previous years.⁵³

Conclusions

Despite increasing rates of substance use in the population, literature on treatment of SUDs for AAPI women remains limited. More emphasis needs to be put on disaggregating subgroup differences in AAPI data to avoid making broad assumptions about the population as a whole. The unique treatment needs and barriers to treatment that AAPI women face should also be further examined. Integrated treatment programs addressing substance use and co-occurring disorders commonly seen in AAPI women should also be further explored to help meet treatment needs and concerns of AAPI women.

Gender-specific treatment programs targeted towards women have been found to be effective in addressing the specialized treatment needs for women with SUDs,⁵⁴ and evidence shows promise for culturally-informed treatments for addressing substance use in AAPI women. Availability of more culturally tailored treatments addressing the specific needs of AAPI women may lead to more acceptability and utilization with the potential for enhanced treatment outcomes for this group. More work is needed to examine how treatment programs can be made more culturally informed and integrative to better serve the needs and increase accessibility to treatment for AAPI women with SUDs.