Advancing Health Equity through Substance Use Research

Abstract

Several health inequities exist among racial/ethnic minoritized populations (REMPs) who use substances including disparities in use patterns, inequities in health and legal consequences of use, as well as in treatment access and effectiveness. To address these inequities, more research is needed to examine the associated factors and identify areas for improving treatment. Divided into three categories, this special issue includes papers that examine the social and contextual factors that are associated with substance use among REMPs, papers that consider the role of racism and discrimination on substance use, and papers that explore racial/ethnic differences in treatment access and outcomes. Recommendations for advancing health equity in substance use research are also included.

The numerous health inequities related to substance use in the United States are undeniable. Racial/ethnic minoritized populations (REMPs) who use substances experience distinct use patterns and disparate rates of long-term health consequences, criminalization, and limited treatment access compared to White counterparts. For example, in 2017, Latin American/Hispanic youth reported a higher rate of illicit substance use than the overall youth population (Substance Abuse and Mental Health Services Administration [SAMHSA] 2020a). Between 2010 and 2013, tobacco use among specific Asian communities (e.g., Korean individuals) was higher than that of others within other Asian communities (Frieden et al. 2016). From 2011 to 2016, Black/African American adults experienced the highest increase in synthetic overdose rates of any racial/ethnic group (SAMHSA 2020b). In 2019, the rate of drug overdose among American Indian/Alaskan Native populations was 41.2% higher than the national rate (Miniño. 2021). Additionally, racial differences in drug-related sentencing often disproportionately criminalize substance use among REMPs (Camplain et al. 2020). REMPs also experience disparities when seeking treatment for substance use. They are more likely to enter treatment later (Montgomery et al. 2019), have lower retention rates (Mennis and Stahler 2016; Saloner and Cook 2013), and are less likely to successfully reduce substance use while in treatment (Sahker et al. 2020) compared to White counterparts.

To better understand the factors that contribute to substance use and its consequences among REMPs, more research is warranted. To address the factors that uniquely influence substance use among REMPs, substance use research must go beyond adding REMP samples to studies designed for White populations without consideration of race/ethnicity and other social-contextual factors. Instead, research projects must follow gold standard methods that capture the unique experiences of different REMPs and examine how these experiences inform substance use (Burlew, McCuistian, and Szapocznik 2021). In this vein, research that better defines racial/ethnic disparities, understands underlying mechanisms of use, and identifies resilience factors that can be leveraged to reduce disparities across multiple REMPs is urgently needed. This special issue addresses this need and highlights research on these topics. The issue begins with papers that consider the role of social and contextual factors on substance use among REMPs. The issue then includes papers that consider the impact of racial discrimination on substance use patterns of REMPs. Finally, the issue ends with papers that consider substance use disparities among REMPs in substance use treatment.

Social and Contextual Factors

Decades of research have highlighted the influence of social and contextual factors on the initiation, misuse, and recovery from substances (Sudhinaraset, Wigglesworth, and Takeuchi 2016). Social and contextual factors cut across domains of influence including the sociocultural context (e.g., social networks, parental education, family functioning, and child-caregiver interactions), the physical/built environment (e.g., neighborhood/community level poverty, income, and resources) and access to quality health care and educational systems (Galea, Nandi, and Vlahov 2004; National Institute on Minority Health and Health Disparities 2021). Social and contextual factors often add to or interact with individual level factors (e.g., race/ethnicity, immigration/nativity, trauma exposure) to amplify risk and/or protection from substance misuse and may accumulate and change over time (Molina, Alegría, and Chen 2012; Thomas 2007).

In this issue, two manuscripts explore a combination of individual-level and social-contextual factors in the use of and recovery from substances. Kim et al. (2021) examines whether perceptions of language brokering stress (i.e., stress related to translating between English and their heritage language for English-Limited parents) change over time within the context of social-contextual stress (e.g., discrimination, foreigner stress, family economic stress), and how stability/change in language-brokering stress increases/decreases risk of cannabis use among Mexican-origin late adolescents. Swan, Aldrige, Joseph, Tucker, and Witkiewitz (2021) examine both individual-level (e.g., age, sex, race/ethnicity etc.) and community-level (e.g., rate of health insurance enrollment, income inequality) factors as predictors of alcohol use disorder (AUD) profiles of recovery three years after receiving treatment. Findings from these papers highlight the importance of assessing and intervening at the social and community level in service of reducing substance use and improving treatment outcomes.

Impact of Discrimination

The past year has seen an unprecedented increase in racial discrimination towards REMPs, including immigrant populations (Addo 2020; Ruiz, Horowitz, and Tamir 2020). Racial discrimination is a major social determinant of health that elicits substantial and prolonged stress and negative affect (Park et al. 2017; Pascoe and Richman 2009), which are prevalent risk factors in the development of substance misuse (Corbin, Farmer, and Nolen-Hoekesma 2013; Sinha and Jastreboff 2013; Laitano et al. 2021). For many decades researchers have documented racial discrimination as a salient contributor to substance misuse, particularly when substances are used to cope with the stress induced by racial discrimination (Amaro et al. 2021; Gerrard et al. 2012). Therefore, efforts to understand substance use from a health equity lens cannot ignore racial discrimination as a major influence.

In this special issue, five manuscripts explore race-related factors that increase the risk of substance use among multiple REMPs including Black/African Americans, Latin American/Hispanics, and immigrant individuals. The articles featured in this section are segmented into three categories: Mechanisms explaining the link between discrimination and substance use (Lanaway & Burlew, 2021), factors that enhance the negative effect of discrimination on substance use (Brown et al., 2021; Espinosa, Bonner, & Alexander, 2021), and individual-level factors that may reduce the risk of substance use among those who are at risk of experiencing racial discrimination (McCabe, 2021; Saint-Fleur & Anglin, 2021). Together, these papers underscore the importance of broadening our understanding of substance use among REMPs by considering the intersection of multiple social determinants (including discrimination) across distinct levels of influence.

SUD Treatment Applications

The National Surveys on Drug Use and Health has shown that the percentage of persons who use drugs has remained consistent over the last several decades, with the prevalence rates differing across various REMPs but ranging from 7–10% among White, Black/African Americans, Latin American/Hispanics, and Indigenous groups) in the United States reporting use (SAMHSA 2019). Despite this, disparities remain in treatment of substance use across racial/ethnic groups. The opioid crisis provides an example. The opioid epidemic (which contributes to a high level of overdose among White individuals) has been categorized as a disease in need of pharmaceutical treatment (Mendoza, Rivera, and Hansen 2019). This contrasted with the “crack cocaine” crisis of the 1980s and 90s in predominantly urban Black populations, where incarceration was the primary intervention (Santoro and Santoro 2018).

REMPs also experience disparities in treatment access, with White individuals who have substance use disorders more likely to have access, insurance, and employment means (work release) to seek treatment at rates higher than Black/African American, Latin American/Hispanic, Indigenous, and other REMPs (Volkow et al. 2019). REMPs also were 37% less likely to complete substance use treatment programs than White counterparts, which could be related to cultural, psychological, and socioeconomic factors that limit attendance and successful completion (Saloner and Cook 2013). Furthermore, many evidence-based approaches for substance use treatment need to be culturally adapted to result in better fit with REMPs (Burlew et al., 2013). It is therefore necessary to develop evidence-based treatment services for REMPs that have been tested clinically with these minoritized groups to obtain the best outcomes in treatment services equity.

Trauma remains a major factor implicated in the initiation of substance use and moderating treatment retention and outcomes, particularly for REMPs (de Arellano and Danielson 2008). In this special issue, two manuscripts examine the relation between trauma and substance use treatment. Shevorykin et al. (2021) explores the effects of trauma exposure on tobacco dependence treatment outcomes for African American adults. White et al. (2021) reviews the literature on indigenous groups and trauma informed approaches to substance use treatment interventions. Social determinants of health have been seen as ongoing barriers to successfully completing treatment programs in minoritized communities. Skewes et al. (2021) review the impact of these barriers on treatment outcomes in Indigenous populations. Finally, McCuistian et al. (2021) examines racial differences in tobacco use and access to nicotine cessation programs across individuals with substance use disorders.

Discussion

The papers in this issue address existing gaps in the substance use literature and comprise a broad and unique set of research topics germane to understanding health disparities in substance use. Although these papers address social contextual factors, race-related factors, and treatment issues, more research is needed.

Conducting additional research on the unique issues facing REMPs who use substances is necessary but not sufficient. Instead, the way forward involves action steps beyond just more research. One essential element is to recruit and retain more REMPs as researchers. Researchers from REMPs can potentially play a pivotal role in moving the field of health disparities research forward. Yet they are underrepresented both among PhD students selected for NIH training support (NIH 2019) and among investigators receiving external research funding (NIH 2018). Increasing opportunities for REMP researchers will benefit not only the individual researchers but the broader field of substance use and treatment.

Recognizing that individuals from REMPs bring a necessary perspective to understanding substance use among REMPs, another component of the way forward is to expand opportunities for National Institute on Drug Abuse and other research panels to benefit from the voices of researchers from REMPs. Including more researchers from REMPs in decision-making roles could result in these individuals raising research questions that warrant exploration, evaluating research proposals, or offering guidance on increasing the relevance of selected research projects. This step could contribute to new and more relevant ways to reduce health disparities.

Finally, alternative approaches may be required to conduct meaningful research on REMPs (Bermúdez, Muruthi, and Jordan 2016; Etowa et al. 2007; Smith 2021). Although the 2017 amendment to the Guidelines for the Inclusion of Women and Minorities attempted to define valid analyses, the amendment only stipulated separate analysis ‘by sex/gender and race/ethnicity’. In earlier publications (Burlew et al. 2019; Burlew, McCuistian, and Szapocznik 2021), we described a set of best practices such as ensuring measurement equivalence, minimizing the use of disputable research designs (e.g., race-comparison designs, combining racial ethnic groups in the analyses) and utilizing randomization methods that result in the equal assignment of racial/ethnic minorities across treatment arms.

In conclusion, the papers in this special issue provide examples of research that adequately explores factors associated with health inequity among REMPs. Infusing the knowledge of REMPs into research and funding decisions as well as relying on alternative methodologies must also be considered to truly address health equity in substance use research.