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S L I D E 0 “Vicissitudes,” Jason DeCaires Taylor, 2007. Caribbean Sea, off the coast of Grenada S L I D E 1 A Moment of Silence

S L I D E 2 239 THOUGHT

OF Equality—As if it harm’d me, giving others the same chances and rights as myself—As if it were not indispensable to my own rights that others possess the same.

Walt Whitman (1819–1892). Leaves of Grass. 1900.

S L I D E 3 Systems of Oppression: The Ecology of Health Disparities in Addiction AMERSA 43rd Annual National Conference November 7, 2019

Ayana Jordan, MD, PhD Assistant Professor, Department of Psychiatry Addiction Psychiatrist, Attending Psychiatrist Connecticut Mental Health Center

S L I D E 4 TEXT AYANAJORDAN646 to 22333 ONCE to JOIN

S L I D E 5 Disclosures

Disclosures • Member of the Board of Trustees for the American Psychiatric Association • Consultant, People’s Preparatory Charter School • Black woman who cares about the experience/needs of Black people and other racial/ethnic minorities who use drugs

S L I D E 6 Conflict of Interest

COI • None I believe: • That RACE is a social construct, not a biological construct. – As such, I do not believe that physiologic racial differences offer adequate explanations for health disparities among people with addiction, including substance use disorders (SUDs). • Racism, both historical and contemporary, is THE “root cause” for these disparities. • If the eradication of Racism was up to Black people and/or people of color, it would have been resolved a long time ago. – Governmental Agencies (NIH, SAMHSA), white people, and white organizations have to want to dismantle Racism and co- lead the charge to do so. • Understanding this is essential for helping racial minorities with SUDs

S L I D E 7 Objectives

• Describe the social and political factors that à health disparities among racial/ethnic under-represented minority (URM) communities

• Identify other commonly used substances in racial/ethnic URM communities that are largely unrecognized in the media

• Describe culturally-informed treatment options for SUDs that are being explored, which may be more acceptable to racial/ethnic URM communities

S L I D E 8 Racial/Ethnic URM Populations with SUD have Worse Outcomes

• Whites >>> use alcohol when c/w Black and Latinx, however the latter with worsening alcohol related illness and neg sequelae – Latinx with higher DUI fatalities • Blacks >>> likely to use cocaine c/w Whites, with higher rates of cocaine-related overdose deaths among Black and Latinx, c/w Whites • Non-medical cannabis use dec for all, but NSDUH odds of cannabis use disorder among adults>>> Black, Native, and Latinx, c/w Whites • Blacks c/w other racial/ethnic groups >>> substance-related disability and premature death • More likely to suffer negative drug-related consequences, including higher rates of Hepatitis C and HIV • Higher rates of involvement in the legal system

Acevedo et al., 2012; Satcher 2001; Schmidt and Mulia, 2009, Galvan, 2003, and Mojtabai R, 2011. Watt TT. The race/ethnic age crossover effect in drug use and heavy drinking. J Ethn Subst Abuse. 2008 https://www.datafiles.samhsa.gov/study/national-survey-drug-use-and-health-nsduh-2003-nid13569

S L I D E 9 Racial/Ethnic URM Populations Less Likely to Initiate Treatment

• Racial\Ethnic URM in US less likely than whites to seek mental health treatment • Blacks compared with racial groups less likely to initiate substance use Tx • Lower treatment engagement • Even when controlling for access through ACA, less engagement in substance use treatment

Mennis, J., & Stahler, G. J. (2016). Racial and Ethnic Disparities in Outpatient Substance Use Disorder Treatment Episode Completion for Different Substances. Journal of Substance Abuse Treatment, 63, 25-33.

S L I D E 10 S L I D E 11 SOCIAL DETERMINANTS OF HEALTH

“[I]nequities in health [and] avoidable health inequalities that arise because of the circumstances in which people grow, live, work, and age...The conditions in which people live and die are, in turn, shaped by political, social, and economic forces.”

World Health Commission on the Social Determinants of Health, 2008.

S L I D E 12 Disparities in SUD Outcomes Medical Problems

Social Determinants of Health: Weathering Racism Housing Incarceration rates Unemployment Parentless Neighborhoods Hopelessness households Policies No Insurance Stress Poverty “Medical baggage” Language Limited Access to Care “Othering” Substance Use Under- Lower graduation rates Education Family Support Poor Working Conditions Teen Births Nutrition

Modified from A. R. James S L I D E 13 CONCEPT of OTHERING

• OTHER (per Oxford dictionary): View or Treat a person or group of people different from or alien to oneself • Being LEFT out of the conversation of mainstream America (whiteness) • Othering has resulted in à Limited focus/funding on Addiction research that affect URM or treatment modalities that respect Culture/Historical Atrocities • URM populations made to feel less than Majority population • No Amends made by Predominately White Institutions of Power to Correct this dynamic • HOT off the press: Black applicants as a group are more likely to propose research topics that are less likely to be funded

https://www.oxfordreference.com https://www.nih.gov/news-events/news-releases/research-topic-contributes-persistent-gap-nih-research-grants-black-scientists

S L I D E 14 ALSO THE BIG “R”

Institutionalized Racism: Differential access to the goods, services, and opportunities of society, by “race” Examples: housing, education, employment, income, medical facilities

Personally-mediated Racism: Differential assumptions about the abilities, motives, and intents of others, by “race” Examples: Police brutality, Physician disrespect, Shopkeeper vigilance, Teacher devaluation

Internalized Racism: Acceptance by the stigmatized “races” of negative messages about your own abilities and intrinsic worth Examples: Self Devaluation, White man’s ice is colder Resignation, helplessness, hopelessness

Jones, CP Levels of Racism: A Theoretic framework and a Gardener's Tale, AmJPublicHealth 2000; 90 (8) 1212-1215

S L I D E 15 Drugs per Dr. Hart…

MUCH OF WHAT HAS GONE WRONG IN THE WAY WE DEAL WITH DRUGS IS RELATED TO CONFUSING THE CAUSE AND EFFECT, TO BLAMING DRUGS FOR THE EFFECTS OF DRUG POLICY, POVERTY, INSTITUTIONAL RACISM, AND MANY OTHER LESS IMMEDIATLEY OBVIOUS FACTORS…

Carl Hart, PhD, High Price: A Neuroscientist’s Journey of Self-Discovery That Challenges Everything You Know about Drugs and Society

S L I D E 16 The Current State of Affairs

• Racial/ethnic URMs have worsening substance use outcomes, esp among Black, Latinx, Natives • But this is IGNORED by Regulatory Agencies (Healthcare, Public Health, Law Enforcement, Policy) and Media

James K, Jordan A: The Opioid Crisis in Black Communities. The Journal of Law, Medicine & Ethics 46:404-21, 2018 C. Hart, ‘People Are Dying Because of Ignorance, not Because of Opioids,’ Scientific American, Nov. 1, 2017 S. Bechteler and K. Kane-Willis, Chicago Urban League, Whitewashed: the African American Opioid Epidemic, Nov. 2017 Cook et al,. Assessing the Individual, Neighborhood, and Policy Predictors of Disparities in Mental Health Care. Med Care Res Rev. Aug, 2017

S L I D E 17 Rate of Opioid Deaths have Increased for ALL Racial Groups

Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services, Results from the 2016 National Survey on Drug Use and Health: Detailed Tables, Sept. 7, 2017

S L I D E 18 Fentanyl Deaths have Drastically Increased, Blacks by 140.6%

Hedegaard, H et. al;. Drugs Most frequently used in drug overdose deaths, in the US, 2011-2016 . National Vital Statistics Reports, Vol. 67, No. 9, December 12, 2018, https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_09-508.pdf

S L I D E 19 Black Overdose Deaths Surpass General Population in 5 States

S. Bechteler and K. Kane-Willis, Chicago Urban League, Whitewashed: the African American Opioid Epidemic, Nov. 2017

S L I D E 20 Regulatory Agencies Advertise to WHITES

S L I D E 21 Clear Focus on White OUD, not marketed for Blacks or Latinx

S L I D E 22 Opioids are not the only Crisis

• Cocaine #2 Killer of Illicit Drugs • Kills More Black Americans than Opioids (Heroin) • Anti-Drug Abuse Act 1986: harsher penalties for crack vs powder cocaine (Prior 11%, since 49%) • Sentencing Disparity between Powder Cocaine and Crack Cocaine (100-1) • > 80% of the defendants sentenced for crack offenses are Black, despite 66% of crack users white or Hispanic.

https://www.nytimes.com/2018/03/05/upshot/overshadowed-by-the-opioid-crisis-a-comeback-by-cocaine.html James, K and Jordan, A. The Opioid Epidemic In Black Communities, The Journal of Law, Medicine, and Ethics, July 2018 ACLU Releases Crack Cocaine Report, Anti-Drug Abuse Act of 1986 Deepened Racial Inequity in Sentencing, October 26, 2006.

S L I D E 23 Media Opinions about Black vs White Drug Use

S L I D E 24 Aide says Nixon’s War on Drugs Targeted Blacks & Hippies:

Washington (CNN): One of Richard Nixon's top advisers and a key figure in the Watergate scandal said the war on drugs was created as a political tool to fight Blacks and hippies, according to a 22-year- old interview recently published in Harper's Magazine. "The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: the antiwar left and Black people,"

former Nixon domestic policy chief John Ehrlichman told Harper's writer Dan Baum for the April 2016 cover story.

S L I D E 25 Nixon’s War on Drugs Resulted in LARGE Incarceration Rates for Black and Latinx When President Nixon declared war on drugs on June 17, 1971, about 110 people per 100,000 in the population were incarcerated. Today, we have 2-3 million prisoners: 743 people per 100,000 in the population.

The U.S. has 5% of the world’s population, but 25% of its prisoners.

Maia Szalavitz, Source: http://www.prisonpolicy.org/global/2016.html

S L I D E 26 Ronald Reagan and ‘War on Drugs’

October 14, 1982, President Ronald Reagan re-declared a “war on drugs,” doubling-down on an initiative that was started by Richard Nixon. Reagan declared that illicit drugs were a direct threat to U.S. national security and through a series of legislation, like the mandatory minimum sentencing laws of 1986, made a hard right turn away from a public health approach to drug use.

By creating mandatory minimum sentencing, drug offenders faced lifetime consequences for minor infractions, yet the focus on tough sentences for crack and not powder cocaine meant the people going to prison were largely Black and Latinx.

https://timeline.com/ronald-nancy-reagan-war-on-drugs-crack-baby-just-say-no-cia-communism-racial-injustice-fcfeadb3548d

S L I D E 27 “The War on Drugs is a war on people, but particularly it’s been a war on low-income people and a war on minorities.”

We know in the United States of America there is minimal difference in drug use between Black, White and Latinx.

But compared to Whites, Latinx populations experience a 2x increased risk of arrest for drug use, and Blacks a 4x increased risk.

S L I D E 28 Arrests Related to Drugs 1971-2001

S L I D E 29 The population of the USA did not change. People of Color did not change. It was a change in our policies, systems and practices that resulted in this increased incarceration rate…policies that preferentially punished certain groups while simultaneously intentionally ignoring others who committed the same or similar crimes.

S L I D E 30 S L I D E 31 ADVOCACY

S L I D E 32 CBPR Research, Social Justice Education, Deliberate Training in URM communities

RESEARCH: • Church Based Pilot Project — providing evidenced based treatment in the church setting • Imani Breakthrough — working with Black and Latinx churches to address SDOH and connect people with MAT EDUCATION: • SJHEC Social Justice and Health Equity Curriculum • Deliberate Recruitment of a Diverse Residency Class CLINICAL TRAINING: • Integration of the Structural Vulnerability Tool into Evals • REACH Recognizing and Eliminating disparities in Addiction through Culturally-informed Healthcare

S L I D E 33 Community Based Participatory Research

CBPR: Partnership approach to research that equitably involves community members, key stakeholders (Black/Latinx people with SUDs), researchers, and others in all aspects of the research process

S L I D E 34 Need to focus on the unique needs of Black people with SUD

Why is the Black Church Relevant?

n Religion and spirituality enable Blacks to cope with psychological distress

n In urban Black communities 65- 80% of adults attend church regularly

n Many studies highlight the importance of church in SUD, where members seek help from clergy

Mattis and Jagers 2001; General Social Survey 2004; Brown, 2006, Sexton et al 2006

S L I D E 35 Overview of PILOT STUDY

Acceptable

Feasible

Recruitment of Substance research Use participants N=40 (Black church and neighborhood)

Recovery Goals Functioning

Figure 9: Overview of Pilot Study: 40 participants, divided into 5 cohorts of N=8, (1) Feasibility (2/3 Retention N=27); (2) Acceptability (Post-intervention satisfaction survey, Qualitative Exit Interview); (3) Substance Use (Urine Tox, Breathalyzer, Brief Symptom Inventory); (4) Recovery Goals (Recovery Markers Questionnaire); (5) Functioning (Quality of Life Scale)

S L I D E 36 Unemployed, Limited Social Supports

DEMOGRAPHICS (N=40) 28% did not complete high school 8% employed 59% were high school graduates 33% disabled 13% completed some college-level work.

64% had never been married or were living alone 46.2 % cocaine, 30.8% alcohol, cannabis, 12.8% and opioids, 10.3%

Half of the sample 53.8% met criteria for SEVERE SUD, DSM 5

S L I D E 37 Significant Reduction in Cocaine and Cannabis Positive Urine Drug Test

Probability of Submitting a Cocaine Positive Urine Specimen Probability of Submitting a Cannabis Positive Urine Specimen Result Over Time Result Over Time For the subset of baseline cocaine positive (note scale) For the subset of baseline MJ positive (note scale) 1

1 0.9 0.9 0.8 0.8 0.7 0.7 0.6 0.6 MJ PositiveMJ Urine

0.5 0.5

Cocaine Positive Urine 0 1 2 3 4 5 6 7 8 0 1 2 3 4 5 6 7 8 Treatment Week Treatment Week

N=22 Wald X2 = 5.71, df = 1, p = .017 N=16 Wald X2 = 8.61, df = 1,p = .003

N=39/40 participants completed the study 6.8 (SD 1.9) Average number of groups attended 78% (n=31) completed all 7 CBT4CBT modules

On a scale of 0-5 (Very Dissatisfied to Very Satisfied) 4.5 (SD=0.89) in response to “How satisfied are you with the treatment you received?”

S L I D E 38 BLACK/LATINX CHURCH BASED PROJECT àMAT

S L I D E 39 Overview of Imani Breakthrough Program

Imani Breakthrough: 2 components over 6 months Part 1: • A group component – 12 weeks of classes and activities 8 Dimensions of Wellness; and the 5Rs of Citizenship enhancement (Roles, Responsibilities, Relationships, Resources, Rights) • Wrap around Support and Coaching – provided during 12 weeks. Coaches provide weekly check-ins assist in goal setting within the scope of the 8 Dimensions of Wellness • Part 2: • Next Step group component – 10 weeks mutual support (post 12 week group).

S L I D E 40 IMANI Socio-demographics N=248

• Gender • Race – Female – 45% – African American – 73% – Male – 54% – White – 16% – Other – 1% – Other – 11% • Age • Ethnicity – Range – 18 to 78 – Hispanic/Latinx – 15% – Mean 49 years old (SD 12)

S L I D E 41 IMANI Type of Substances Used

• Tobacco – 62% • Alcohol – 52% • Cannabis– 45% • Cocaine/Crack cocaine – 36% • Heroin – 16% • Opioid--Pain killer – 7% • Other opioids – 4% • Tranquilizer – 4% • PCP – 4% • Other (Meth, hallucinogen, inhalant, etc.) – 5%

S L I D E 42 IMANI SDOH Breakdown

HOMELESSNESS • 74% have experienced homelessness

• 47% of whom have experienced homelessness 2 or more times

INCARCERATION • 62% have been incarcerated

• 12% are currently on probation or parole

S L I D E 43 Disparities in SUD Outcomes Medical Problems

Social Determinants of Health: Weathering Racism Housing Incarceration rates Unemployment Parentless Neighborhoods Hopelessness households Policies No Insurance Stress Poverty “Medical baggage” Language Limited Access to Care “Othering” Substance Use Under- Lower graduation rates Education Family Support Poor Working Conditions Teen Births Nutrition

Modified from A. R. James S L I D E 44 I am often asked...which Social Determinants

to address? Poverty

Every community is different: • Begin where you reach consensus • Where the community has the most strength or greatest will/need Education • Schedule a time-table for on-boarding RACISM interventions that address all Policy Social Determinants

Employment Housing

Gap

Lack of Education

community resourced Under Wealth Teen Pregnancy

Racism Ethnic Minority Ethnic

Employment

Poverty

Modified from A. R. James

S L I D E 45 Increasing the Addiction Workforce Trained in CI Care

S L I D E 46 Acknowledgements

• Kathleen Carroll, PhD (All of the members of her TEAM!) • Chyrell Bellamy, PhD, Peer Recovery Coaches/Facilitators • Church Based Health Advisors • Reverend Frederick Streets, Senior Pastor, Dixwell Church • Pastor Kelcy Steele, Senior Pastor, Varick AME • Cultural Ambassadors Program at YCCI • Pilot participants, Dixwell/Newhallville community • Larry Davidson, PhD, Ismene Petrakis, MD, Mehmet Sofuoglu, MD • Kathryn Cates-Wessel • Jeanette Tetrault, MD • Ellen Edens, MD • Lloyd Cantley, MD, Eugene Shapiro, MD, Rajita Sinha, PhD, Tesheia Johnson, MBA Yale Center for Clinical Investigation (YCCI), CTSA Grant KL2 TR001862 from the National Center for Advancing Translational Science (NCATS), a component of the National Institutes of Health (NIH)

• James Sorensen, PhD and Carmen Masson, PhD UCSF Learning for Early Careers in Addiction and Diversity (LEAD) Program, funded by National Institute on Drug Abuse. R25 DA035163

S L I D E 47 Questions?

Jordan Wellness Collective [email protected]

@DrAyanaJordan

[email protected]

Ayana Jordan

S L I D E 48 References

• Substance Abuse and Mental Health Services Administration. (2018). Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/. Updated: March 14, 2018 • Huhn AS1, Dunn KE2, Why aren't physicians prescribing more buprenorphine? J Subst Abuse Treat. 2017 Jul;78:1-7. doi: 10.1016/j.jsat.2017.04.005. Epub 2017 Apr 12. • Centers for Disease Control and Prevention, National Dencter for Health Statistics. Muliple Cause of Death 1999-2017 on CDC Wonder. Online Database, Released December, 2018 • Drug deaths in america are rising faster than ever, Josh Katz. New York Times June 5, 2017 https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html • Addiction Rare in Patients Treated with Narcotics. January 10, 1980. N Engl J Med 1980; 302:123 DOI: 10.1056/NEJM198001103020221 • OxyContin Marketing Plan, 2002.” Purdue Pharma, Stamford, CN, 2002 • Van Zee A. (2009). The promotion and marketing of oxycontin: commercial triumph, public health tragedy. American journal of public health, 99(2), 221-7 https://www.pharmaceutical-journal.com/opinion/ • https://www.pharmaceutical-journal.com/opinion/comment/the-prescription-opioid-addiction-and-abuse-epidemic-how-it-happened-and-what- we-can-do-about-it/20068579.article?firstPass=false • James K, Jordan A: The Opioid Crisis in Black Communities. The Journal of Law, Medicine & Ethics 46:404-21, 2018 • C. Hart, ‘People Are Dying Because of Ignorance, not Because of Opioids,’ Scientific American, Nov. 1, 2017. • S. Bechteler and K. Kane-Willis, Chicago Urban League, Whitewashed: the African American Opioid Epidemic, Nov. 2017 • Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services, Results from the 2016 National Survey on Drug Use and Health: Detailed Tables, Sept. 7, 2017 • K.Q. Seelye, ‘In Heroin Crisis, White Families Seek Gentler War on Drugs,’ New York Times, Oct. 30, 2015. • J. Stockbridge and L. Rothman, ‘A Caring Lens on the Opioid Crisis, Time Magazine, 2012. • M. Talbot, ‘The Addicts Next Door,’ New Yorker, June 5, 2017, • Alexander, M et. Al. Trends in Black and White Opioid Mortality in the United States, 1979–2015. Epidemiology: September 2018 - Volume 29 - Issue 5 - p 707–715. doi: 10.1097/EDE.0000000000000858 • https://www.narconon.org/drug-information/heroin-history-1900s.html • Mukku, V. K., Benson, T. G., Alam, F., Richie, W. D., & Bailey, R. K. (2012). Overview of substance use disorders and incarceration of african american males. Frontiers in psychiatry, 3, 98. doi:10.3389/fpsyt.2012.00098 • https://pediatrics.aappublications.org/content/pediatrics/143/2/e20182752.full.pdf

S L I D E 49 References continued

• E. Drucker, ‘Population impact of mass incarceration under New York's Rockefeller drug laws: an analysis of years of life lost,’ Journal of Urban Health Bulletin of the New York Academy of Medicine, 79, no. 3 (2002): 434-444. • ACLU, War Comes Home: The Excessive Militarization of American Police, June 2014 • Report says U.S. jails more blacks than whites for drugs,’ Reuters, Dec. 4, 2007 • ACLU, Racial Disparities in Sentencing, Oct. 27, 2014 • Hedegaard, H et. al;. Drugs Most frequently used in drug overdose deaths, in the US, 2011-2016 . National Vital Statistics Reports, Vol. 67, No. 9, December 12, 2018. https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_09-508.pdf • Child Trends analysis of the National Survey on Drug Use and Health from the Substance Abuse and Mental Health Services Administration (SAMHSA) Data Archive; https://www.childtrends.org/; https://pediatrics.aappublications.org/content/pediatrics/143/2/e20182752.full.pdf • https://www.nytimes.com/2018/03/05/upshot/overshadowed-by-the-opioid-crisis-a-comeback-by-cocaine.html • ACLU Releases Crack Cocaine Report, Anti-Drug Abuse Act of 1986 Deepened Racial Inequity in Sentencing, October 26, 2006. • https://www.nih.gov/research-training/medical-research-initiatives/heal-initiative • Acevedo A, Garnick DW, Lee MT, Horgan CM, Ritter G, Panas L, Davis S, Leeper T, Moore, R, Reynolds, M. Racial and Ethnic Differences in Substance Abuse Treatment Initiation and Engagement. J Ethn Subst Abuse. 2012;11(1): 1–21. • Satcher D. Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. 2001. http://www.ncbi.nlm.nih.gov/books/NBK44243. Accessed June 25, 2016. • Schmidt, L.A. and Mulia, N.; Racial/Ethnic Disparities in AOD Treatment Knowledge Asset, Web site created by the Robert Wood Johnson Foundation's Substance Abuse Policy Research Program; February 2009.,http://saprp.org/knowledgeassets/knowledge_detail.cfm?KAID=11 • Journal of Community Psychology, 29(5): 519-539. • General Social Survey. (2004). Association of Religion Data Archives, Accessed at, http://www.thearda.com • Brown, EJ. (2006). The integral place of religion in the lives of rural African-American women who use cocaine, Journal of Religion and Health, 45(1):19-39. • Sexton RL, Carlson RG, Siegal H, Leukefeld CG, Booth B. (2006). The role of African-American clergy in providing informal services to drug users in the rural South: Preliminary ethnographic findings, Journal of Ethnicity and Substance Abuse; 5(1):1-21. • Hankerson SH, Lee YA, Brawley DK, Braswell K, Wickramaratne PJ, Weissman MM. Screening for Depression in African-American Churches. Am J Prev Med. 2015 Oct;49(4):526-33. • Hankerson SH, Weissman MM. Church-based health programs for mental disorders among African Americans: A review. Psychiatric Services, 2012; 243-249. • Stahler GJ, Kirby KC, Kerwin ME: A Faith-Based Intervention for Cocaine-Dependent Black Women. Journal of Psychoactive Drugs 39:183- 90, 2007

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