Cultural competency still elusive among addiction medicine providers

In spite of its long history, the field of addiction medicine remains relatively new within the U.S. healthcare framework.

From criminalization and “Just Say No” campaigns to the use of medication, behavioral therapy and harm reduction strategies, the evolution of addiction medicine has largely coincided with the racial makeup of the populations at the time that were hardest hit by a drug epidemic.

Racial makeup also affected drug marketing campaigns, particularly for opioid makers who focused their prescription pain medication ads toward largely white, middle-class patients.

“There was this assurance that the target patients would be safe, trustworthy consumers that were not at high risk from addiction,” said Dr. Helena Hansen, associate director of the Center for Social Medicine at UCLA David Geffen School of Medicine. “That whole perception was based on a whole century of racial class imagery around who is at risk for addiction.”

The current opioid crisis has had a disproportionate impact on white communities, thanks largely to those marketing campaigns. Approximately 72% of all drug overdose deaths in 2019 were white individuals, according to figures from the Kaiser Family Foundation.

But the racial lines are shifting again. In recent years, an increasing proportion of overdose deaths are Black and Latino individuals rather than white. Experts say addiction medicine needs to develop treatment approaches that can address an individual patient’s cultural background and socioeconomic needs as those demographics shift.

“Addiction really occurs at the intersection between mental health, physical health and social existence,” said Dr. Miriam Komaromy, medical director for the Grayken Center for Addiction at Boston Medical Center. “So all kinds of cultural things come into play in the development of addiction, what patients may want for treatment, and how they respond to treatment.”

People of color can experience a vastly different set of circumstances around their addiction compared to white individuals, and that can impact the success of their recovery, Komaromy said. Blacks accounted for more than one in every four drug law violations in 2015 despite having similar drug use rates as all other ethnicities and racial groups, according to a 2018 report by criminal justice reform advocacy group the Sentencing Project. Blacks and Latinos make up 56% of individuals imprisoned for a drug offense and were more likely than whites to be incarcerated for a drug offense rather than diverted into a drug treatment program.

People of color have fewer avenues to accessing addiction treatment. Only 16% of patients who were treated in an emergency department for opioid overdose accessed some form of drug treatment following their visit, according to a study published last month in JAMA Network Open. Access to care was even more limited for Black overdose patients; only 6% received follow-up addiction treatment services.

Other research has found Black youth with substance use disorder were 42% less likely to be prescribed medication-assisted treatment. A 2019 JAMA Psychiatry study concluded Black patients with SUD were 77% less likely to receive the addiction treatment medication buprenorphine.

Those statistics highlight why people of color are more likely to have their first experience with drug treatment in jail or prison, Hansen said.

“It completely colors their experience of addiction treatment because it is often given in a punitive way,” Hansen said.

Those perceptions, socioeconomic issues and cultural barriers like language have all contributed to why Black and Latino patients were three to eight times less likely than white patients to complete addiction treatment.

While it’s important to recruit a more diverse workforce of addiction medicine specialists to address those cultural differences, that mentorship needs to begin early in the educational pipeline, Komaromy said.

Grayken mentors high school students to raise their awareness about addiction medicine careers. The U.S. Substance Abuse Mental Health Services Administration launched a five-year program in 2018 to help create a more diverse addiction treatment workforce.

Clinicians and students can also learn directly from their patients by incorporating advisory boards and in-depth focus groups to hear their experiences and whether they feel respected and heard.

But there still needs to more research on cultural competency in addiction treatment. Developing more standardized approaches in treatment plans could improve patients’ experiences with addiction treatment and help specialists better understand racial trauma, Komaromy said.

Waltham, Mass.-based behavioral health and addiction medicine provider Eleanor Health has emphasized that its clinicians must listen and remain open-minded to their patients clinical and non-clinical needs. The organization’s approach focuses on cultural humility rather than competency, according to Dr. Nzinga Harrison, co-founder and chief medical officer.

Eleanor Health tracks its outcome data quarterly by race and ethnicity to look for health disparities. It shares results throughout the organization to encourage accountability and quality improvement.

“If you’re not looking at data then you have a blind spot,” Harrison said. “You’re missing an opportunity to close a health disparity gap as it relates to treating addiction.”

A large component of their care equity work is tied to their financial model, Harrison said. Eleanor Health contracts in value-based reimbursement arrangements with Medicaid managed care programs in several states.

“When you move to really being accountable and embedding equity within those quality metrics, it changes the way you run your business,” Harrison said. “You have to find a way to address those disparities or you have financial risk.”