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. Author manuscript; available in PMC: 2019 Feb 1.
Published in final edited form as: Addict Behav. 2017 Sep 1;77:63–66. doi: 10.1016/j.addbeh.2017.08.029

Perceived Discrimination and Drug Involvement among Black Primary Care Patients Who Use Drugs

Kathryn E Chavez 1, Tibor P Palfai 1, Leah E Squires 2, Debbie M Cheng 3, Christine Lloyd-Travaglini 4, Richard Saitz 5
PMCID: PMC5772706  NIHMSID: NIHMS909783  PMID: 28965068

Abstract

Perceived discrimination has been associated with disparities for Black patients on a variety of health outcomes. Studies have suggested that perceived discrimination is associated with drug use in Blacks, but they have been limited by use of samples with little drug use and single measures of drug involvement. The current study examined the association between perceived discrimination and multiple measures of drug involvement among a sample of 203 Black adult primary care patients who were participants in a randomized trial of screening and brief intervention for drug use. The main independent variable was everyday perceived discrimination. The three outcomes were frequency of drug use in the past ninety days, drug-related consequences, and total drug involvement risk severity score from the Alcohol, Smoking, and Substance Involvement Test [ASSIST]. Analyses were conducted using negative binomial regression models for frequency and consequence outcomes and median regression models for drug involvement risk. Greater perceived discrimination was not significantly associated with frequency of use, but was associated with more drug-related consequences and a higher drug use risk level. These findings suggest that perceived discrimination may be an important variable to consider when selecting drug intervention approaches for Black primary care patients.

1. INTRODUCTION

Previous research has provided evidence for the association between perceived discrimination and negative health outcomes, notably the use of illicit drugs (Paradies, 2006; Pascoe & Richman, 2009; Williams, Neighbors & Jackson, 2003). The impact of perceived discrimination on drug use may be particularly acute for Blacks who experience high rates of discrimination in their daily lives (Clark et al., 1999). There have now been a number of studies that have demonstrated an association between perceived discrimination and (1) substance use rates (Fuller-Rowell et al., 2011), (2) past year and frequent drug use (Carliner et al., 2016), (3) lifetime drug use (Borrell et al., 2007) and (4) the diagnosis of substance use disorder (Hunte & Barry, 2012; Clark et al., 2015).

Despite evidence for the association between perceived discrimination and drug use among Blacks in general population samples, relatively little is known about how discrimination is associated with drug use patterns among identified drug users. The majority of studies examining this association have used community (e.g., Gibbons et al., 2014) or university samples (e.g., Latzman, Chan & Shishido, 2013): subpopulations with typically low rates of drug use. Moreover, previous studies have typically selected single indicators of drug involvement, such as the presence of drug use (e.g., Clark et al., 2014), use frequency (e.g., Carliner et al., 2016), or the presence of a clinical substance use disorder (e.g., Hunte & Barry, 2012). Examination of multiple outcomes of drug use may provide a more differentiated understanding of how discrimination is associated with drug use patterns and risks within specific populations. Increased knowledge of the impact of perceived discrimination on drug use patterns among drug users is critical to inform intervention approaches for Black drug users: a group that experiences elevated drug-related health risk compared to non-Black drug users (Gil et al., 2004).

The current study examined the association between perceived discrimination and drug-related outcomes in a sample of Black adults who reported drug use during screening in a primary care setting. The primary aim was to examine the association between perceived discrimination and drug use frequency, consequences, and drug involvement risk level among identified drug users. It was hypothesized that perceived discrimination would be positively associated with drug use across these three indices. Exploratory stratified analyses were conducted to examine whether these associations were similar for marijuana versus other drugs. The current study is a secondary data analysis from the ASPIRE study: a randomized controlled trial of brief interventions among adults in a primary medical care setting who screened positive for drug use (see Saitz et al., 2014 for full description). To our knowledge, this is the first study to examine perceived discrimination and drug use among Black patients who use drugs identified by screening in primary care.

2. MATERIALS AND METHODS

2.1 Participants

Participants were 203 Black primary care patients enrolled in a randomized controlled trial of a brief intervention for drug use. Eligibility criteria included being at least 18 years of age and a drug-specific involvement score ≥ 2 based on self-report responses to The Alcohol, Smoking and Substance Involvement Screening Test [ASSIST].

2.2 Measures

Perceived discrimination was measured with the nine-item Everyday Discrimination questionnaire (Williams et al., 1997), assessing experiences of unfair treatment in day-to-day life (e.g., being treated with less courtesy than others). This measure has been utilized in multiple studies of discrimination and health outcomes. Respondents rate the frequency with which they experience unfair treatment (e.g., “You are called names or insulted”) using a six-point scale (i.e., “never” to “almost every day”). Internal consistency of the measure was excellent in the current sample (Cronbach’s alpha = 0.86). Mean-item score for each subject was used in regression analyses to facilitate interpretation of outcomes.

Three drug use outcome measures were collected. The Time Line Follow-Back-90 [TLFB-90] (Westerberg, Tonigan & Miller, 1998) was used to measure the number of days that each patient used his/her main drug of concern over the previous ninety days. The Short Inventory of Problems-Drug [SIP-D] was used to measure drug-related consequences over the past 3 months (Alterman, Cacciola, Ivey, Habing & Lynch, 2009). The ASSIST was used to assess drug involvement risk level (World Health Organization ASSIST Working Group, 2002). Among other indices, the ASSIST provides an overall measure of drug use risk known as the Total Drug Involvement score [ASSIST-TDI] that includes items such as pre-occupation with use, harmful use, impaired control, and craving. Measures of discrimination and drug use for this study were collected six months after enrollment in the RCT.

2.3 Covariates

Age, gender, intervention condition, and marijuana as main drug (yes/no) were selected a priori as covariates for analyses because of their potential as confounders of the association between perceived discrimination and drug outcomes of interest.

2.4 Procedures

In the ASPIRE trial, participants were randomly assigned to one of two intervention groups or a control group, and completed follow-up assessments six months following baseline (Saitz et al., 2014). At baseline, participants completed several questionnaires of drug use (described above) and demographics. Main drug was identified by the patient as the drug that concerned him/her the most, and provided the basis for primary drug use outcomes (Saitz et al., 2014). At six-month follow-up, participants completed the perceived discrimination measure and three drug use measures (TLFB-90, SIP-D, ASSIST). The Institutional Review Board of Boston University Medical Campus approved all enrollment and study procedures.

2.5 Data Analytic Strategy

Prior to testing the study hypotheses, descriptive statistics were generated for all study variables. Preliminary analyses suggested the linearity assumption was reasonable for modeling the relationship between perceived discrimination and both drug-related consequences and drug involvement risk levels, therefore discrimination was modeled as a continuous variable for these analyses. The linearity assumption was not met for the relationship between perceived discrimination and drug use frequency measure (TLFB-90) and thus, Everyday Discrimination mean scores were categorized into quartiles for analyses of drug use frequency. Consistent with the main trial paper (Saitz et al., 2014), TLFB and SIP-D (non-negative integers) were analyzed as count data using negative binomial regression (to allow for overdispersion in the data as the variance exceeded the mean) and median regression was used to analyze ASSIST-TDI outcomes due to a nonnormal distribution (Hao & Naiman, 2007; Koenker, 2005). Confirmatory analyses were conducted for both TLFB and SIP-D using median regression models. Covariates included gender, age, intervention condition, and marijuana as main drug (yes/no). A parallel set of exploratory analyses were conducted by stratifying on whether marijuana was the main drug or not (rather than using this variable as a covariate as in the primary analyses). Regression models were fit for each outcome variable separately.

3. RESULTS

3.1 Descriptive Statistics

Participant characteristics are presented in Table 1. Mean age for the sample was 44.1 years (SD = 12.2). Sixty-five (32%) participants were women. Marijuana was the most frequently reported main drug (67%). The mean of each outcome was as follows: frequency of main drug use was 42.69 days (SD = 36.16); mean ASSIST-TDI score was 21.79 (SD = 17.92); and mean SIP-D score was 7.02 (SD = 9.79). The total scale score for the Everyday Discrimination scale ranged from 9 to 54 with a mean (SD) of 20.23 (10.69). The mean-item scores for this sample was generally low (mean (SD) item score = 2.25 (1.19).

Table 1.

Sample Characteristics (N = 203)

Variable
Age, mean (SD) 44.1 (12.2)
Gender
 Men (%) 138 (68%)
 Women (%) 65 (32%)
Main Drug
 Marijuana 136 (67%)
 Other 67 (33%)
Intervention Condition
 Control n (%) 64 (31.5%)
 Brief Negotiated Interview n (%) 71 (35%)
 Motivational Intervention n (%) 68 (33.5%)
Perceived Discrimination
 Everyday Discrimination item measure, mean (SD) 2.25 (1.19)
Drug of Most Concern Frequency
 Time Line Follow-Back-90, mean (SD)a 42.69 (36.16)
 Time Line Follow-Back-90, median (IQR)b 39 (4, 83)
Drug-related Consequences
 SIP-D, mean (SD)c 7.02 (9.79)
 SIP-D, median (IQR) 2 (0, 11)
Drug Use Risk
 ASSIST- TDI, mean (SD)d 21.79 (17.92)
 ASSIST-TDI, median (IQR) 18 (9, 29)
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Notes:

a

Number of days using main drug from the ninety-day Timeline Follow-back [TLFB-90];

b

IQR = interquartile range (25th and 75th percentiles).

c

Past 3-month drug-related consequences from the Short Inventory of Problems-Drugs [SIP-D];

d

Total Drug Involvement score from the Alcohol, Smoking, and Substance Involvement Test [ASSIST].

3.2 Association between Perceived Discrimination and Drug Use Outcomes

Perceived discrimination was not significantly associated with frequency of drug use in the past ninety days as measured by the TLFB-90 (global p = 0.08). Higher levels of perceived discrimination (indicated by second through fourth quartiles on the Everyday Discrimination scale) were not associated with higher use frequency compared to the lowest quartile. Conversely, higher Everyday Discrimination scores were associated with significantly higher SIP-D scores as indicated by the adjusted incidence rate ratio (aIRR = 1.36; 95% CI, 1.18–1.57, p < 0.01)1. Similarly, median regression analyses of the ASSIST-TDI score indicated that Everyday Discrimination scores were associated with higher levels of drug involvement risk in the adjusted model (β = 3.29; 95% CI, 1.36–5.23, p < .01).

3.2.1 Association between Perceived Discrimination and Drug Outcomes Stratified by Main Drug

Analyses of the TLFB data did not clearly support the view that the perception of more discrimination would be associated with more frequent drug use for either category of drug. Perceived discrimination was not associated with the frequency of drug use among those with marijuana as a main drug (global p = .08). For those with a drug other than marijuana as their main drug (global p < .01), those in the second quartile of Everyday Discrimination scores reported less frequent drug use compared to those in the lowest quartile, but no significant differences were observed between the lowest quartile and the other quartiles. For the SIP-D measure, the impact of perceived discrimination was similar in both main drug strata: a positive association was observed for both those who had marijuana and for those who did not have marijuana as main drug (respectively: aIRR = 1.41; 95% CI, 1.14–1.75, p = < 0.01, aIRR = 1.31; 95% CI, 1.10–1.56, p < 0.01). For the ASSIST-TDI score outcome, perceived discrimination was associated with higher levels of drug involvement risk among those with marijuana as the main drug in the adjusted model (β = 3.40; 95% CI, 1.37–5.42, p < 0.01), but not among those with other drugs as main drug (β = 1.35; 95% CI, −3.67–6.37, p = 0.59).

4. DISCUSSION

The current study showed that perceived discrimination is associated with drug-related consequences and level of drug involvement risk among Black primary care patients who use drugs. In contrast, results did not provide evidence of an association between perceived discrimination and frequency of drug use. Exploratory analysis stratifying by main drug generally replicated the primary results, with the exception that perceived discrimination was not significantly associated with level of drug involvement risk among those who identified a drug other than marijuana as their main drug. This may be partly due to the heterogeneity of this category, characteristics of drug involvement risk level associated with use of these drugs, and power to detect effects with this smaller subsample.

These findings provide a more nuanced perspective of drug use involvement among Black drug users. The fact that perceived discrimination was associated with drug use risk and consequences than drug use frequency is consistent with the view that discrimination may act as a chronic stressor (Carliner et al., 2016). A number of studies have shown that coping-related motives for substance use may be particularly linked with negative consequences (Gerrard et al., 2012). Perceived discrimination may add to the already higher levels of stress experienced by this population (Amey & Albrecht, 1998; Jones-Webb et al., 1997; Wilson, 1987), and may, in part, account for the higher rates of drug-related consequences in the absence of higher frequency of use among Blacks (Gil et al., 2004; Atkins et al., 2014). Given the association with negative consequences and risk for substance use disorders, it is important that clinicians attend to the potential effects of perceived discrimination and its associated stress when developing interventions for this population.

This study is not without limitations. The sample consisted of patients who were part of a brief intervention trial and conclusions were based on cross-sectional analyses of six month outcomes. Despite these limitations, this study represents the first to demonstrate an association between perceived discrimination and drug-related harm among this population. Future work should examine the role of discrimination in prospective analyses and consider potential mediators such as anger and depression (e.g., Gibbons et al., 2014), and the formation of high risk social networks (Crawford, Ford, Kim, & Lewis, 2016) to better understand how discrimination may influence drug-related outcomes. A comprehensive understanding of the relationship between perceived discrimination and drug use outcomes can inform screening and intervention strategies for Black patients who use drugs.

4.1 Conclusions

The results of this study indicate that among primary care patients reporting drug use, perceived discrimination may be associated with drug involvement risk level and consequences. These findings highlight the importance of considering the potential impact of when developing interventions for Black primary care patients who use drugs.

Table 2.

The association between perceived discrimination and drug-related outcomes

Unadjusted Model Primary Adjusted Model
IRR (95% CI) aIRR (95% CI)
Number of days main drug use
Overall sample (N = 203) global p = 0.22 global p = 0.08
 2nd quartile 0.92 (0.69–1.39) 0.81 (0.56–1.15)
 3rd quartile 1.22 (0.91–1.62) 1.26 (0.89–1.77)
 4th quartile 0.88 (0.62–1.24) 1.02 (0.66–1.58)
Marijuana (N = 136) global p = 0.03 global p = 0.08
 2nd quartile 1.05 (0.77–1.41) 1.00 (0.74–1.36)
 3rd quartile 1.30 (1.02–1.66)+ 1.23 (0.96–1.58)
 4th quartile 0.88 (0.62–1.26) 0.79 (0.55–1.14)
Other Drugs (N = 67) global p < 0.01 global p < 0.01
 2nd quartile 0.22 (0.07–0.68)* 0.24 (0.08–0.74)+
 3rd quartile 1.26 (0.52–3.09)+ 1.12 (0.45–2.77)
 4th quartile 1.26 (0.51–3.13) 1.67 (0.61–4.56)
SIP-D
Overall sample (N = 203) 1.39 (1.21–1.60)* 1.36 (1.18–1.57)*
Marijuana (N = 136) 1.39 (1.12–1.71)* 1.41 (1.14–1.75)*
Other Drugs (N = 67) 1.30 (1.10–1.55)* 1.31 (1.10–1.56)*
ASSIST- TDI
β (95% CI) adjusted-model β (95% CI)
Overall sample (N = 203) 2.79 (0.75–4.84)* 3.29 (1.36–5.23)*
Marijuana (N = 136) 2.91 (1.00–4.82)* 3.40 (1.37–5.42)*
Other Drugs (N = 67) 2.18 (3.67–8.04) 1.35 (−3.67–6.37)
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Notes: The primary regression models adjust for age, gender, marijuana use, randomization group. Frequency of drug use and drug-related consequences were modeled using negative binomial regression. Note that aIRR refers to the covariate adjusted incidence rate ratio. SIP-D refers to the Short Inventory of Problems-Drug total score. For analyses with frequency outcomes, perceived discrimination scores are represented as quartiles. Comparisons are made with the first (lowest) quartile as the reference group. The ASSIST-TDI refers to the Total Drug Involvement score from the Alcohol Smoking and Substance Involvement Test. Median regression was used for analyses of ASSIST-TDI outcomes and beta-weights for adjusted and unadjusted models are presented.

+

p< 0.05

*

p < 0.01

Highlights.

  • Examined the association between perceived discrimination and multiple measures of drug involvement among a sample of Black adult primary care patients.

  • Findings suggest that higher perceived discrimination was not significantly associated with frequency of use, but was associated with drug-related consequences and increased drug use risk for these patients.

  • Results highlight the importance of considering the unique impact of perceived discrimination when developing interventions for Black primary care patients who use drugs.

Acknowledgments

Role of Funding Sources

This research was supported in part by a grant from the National Institute on Drug Abuse, DA029227-01A1 to Dr. Richard Saitz.

Footnotes

1

Sensitivity analyses were conducted for TLFB and SIP-D data using median regression analyses. Results of these analyses confirmed negative binomial regression results for drug use frequency and consequences.

Contributors

All authors have contributed to the research and manuscript preparation.

Tibor P. Palfai contributed to all facets of the study including design, analyses and manuscript preparation.

Leah E. Squires contributed to design, analyses and manuscript preparation.

Debbie Cheng contributed to project implementation, randomization procedures, statistical analyses and manuscript preparation.

Christince Lloyd-Travaglini contributed to project implementation and manuscript preparation.

Richard Saitz contributed to design, analyses and manuscript preparation.

Conflict of Interest

There are no conflicts of interest to declare

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