Advancing Racial Justice and Health Equity

Advancing Racial Justice in Addiction Medicine

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Background

Addiction involves complex interactions among an individual’s brain circuits, genetics, the environment, and their life experiences.(1) Racism disproportionately shapes the environment and life experiences of Black, Hispanic/Latinx, Asian, Pacific Islander, Native American, and other racially oppressed and disenfranchised people (hereinafter collectively referred to as Black, Indigenous, People of Color (BIPOC), adversely influencing both their risk of developing addiction and their access to evidence-based addiction treatment services. While police and civilian murders of Black people in the United States of America have highlighted the deadly consequences of racism, they have also illuminated the impact of the long-standing systemic racism in the United States. Systemic racism has been defined as “a system in which public policies, institutional practices, cultural representations, and other norms work in various, often reinforcing ways to perpetuate racial group inequity. ⁽²⁾

This is the first of a series of policy statements on racial justice through which ASAM reiterates the fundamental axiom that systemic racism is a social determinant of health(3) that has had profound, deleterious effects on the lives and health of BIPOC. These statements are part of ASAM’s effort to recognize, understand, and then counteract the adverse effects of America’s historical, pervasive, and continuing systemic racism, specifically with respect to addiction prevention, early intervention, diagnosis, treatment, and recovery. The goal of this series is to increase structural competency, defined as “the capacity… to recognize and respond to health and illness as the downstream effects of broad social, political, and economic structures,”(4),(5) among addiction medicine professionals, public health authorities, policymakers and others with societal influence or authority. Structural competency bridges research on social determinants of health with clinical interventions, and prepares clinical trainees to act on systemic causes of health inequalities.

ASAM recognizes the racism and discrimination that BIPOC patients, their families, and addiction medicine professionals consistently face in their personal and professional lives. Every day, addiction medicine professionals confront the tragic consequences of racial injustice among the patients and communities we serve — from the disproportionate incarceration of BIPOC with the disease of addiction, to treatment barriers for many BIPOC, to rising overdose deaths and ongoing discrimination. (6), (7) ASAM denounces and commits to challenging racial injustice by working toward solutions to the addiction crisis that recognize the role of systemic racism in creating and reinforcing health inequities. ⁽⁸⁾

Drug policy has supported systemic racism. Drug controls arose from a mix of motives, some of which were laudable, but many of which were based in racist ideology. Racial bias has emerged in policies as written and applied.

The impact of systemic racism in drug policy and addiction medicine is evident in:

• De-medicalization (from medicalization to criminalization): Addiction medicine is older than criminalization, but this initial era ended with the passage of the 1914 Harrison Narcotic Tax Act (Ch. 1 38 Stat 785) (HNTA). The passage of the HNTA as well as its enforcement was dominated by explicit racism directed against immigrant Asian and Hispanic/Latinx labor, Black men and concern about women stolen into “white slavery(9) and it ushered in a period that prioritized policing over public health.

• Criminal legal reform failures: Mandatory sentencing guidelines, codified in the 1984 Sentencing Reform Act, were intended to address racial inequities in the criminal legal system. However, unguided discretion at the local and prosecutorial level worsened inequities primarily through guilty pleas rather than judicial action. Systemic racism in drug policy is perhaps most easily recognized in the Anti-Drug Abuse Act of 1986, which enacted a 100-fold greater sentencing disparity for water-insoluble cocaine base (“crack”) versus powder cocaine.
• Selective and discriminatory recognition of addiction as a medical condition: The federal and state response to crack use in the 1980s and 1990s focused funding on law enforcement, which was then targeted at BIPOC. Conversely, three-quarters of federal funding to address the opioid epidemic, associated more closely with white people, went to research, treatment, and prevention.(10) Media portrayals of Black and Hispanic/Latinx people who use heroin as criminals and white people who use prescription opioids as sympathetic victims reinforced the racialized policy response to drug use.⁽¹¹⁾
• Inequitable expansion of treatment: Motivated, in part, by an association of the opioid crisis with white people and in response to the historic location of addiction treatment with the criminal legal system, the Drug Addiction Treatment Act of 2000 (DATA 2000) was enacted to expand care in the medical setting. However, the benefit of expanded treatment has been unequal. Opioid use disorder (OUD) treatment remains segregated, with Black and Hispanic/Latinx people more likely to receive methadone, ⁽¹²⁾ which is only available in highly regulated systems, and white people more likely than people of other races to receive buprenorphine, which is available in an office- based setting.⁽¹³⁾
• Beyond the multiple problems with the treatment of OUD, neglect of the health concerns of BIPOC communities continues in other ways: In 2020, sales restrictions were placed on flavored tobacco products except for those featuring menthol, the product most often used by Black people.⁽¹⁴⁾ In essence, this prioritized tobacco company profits over the health of Black people. In addition, alcohol outlet density remains far greater in Black and Hispanic/Latinx neighborhoods.⁽¹⁵⁾ Some have argued that this fact reflects structural racism in the built environment.^(16)(17)

The contemporary consequence of this racist history is seen in:

• The lack of focus on evidence-based SUD prevention research among BIPOC⁽¹⁸⁾, ⁽¹⁹⁾ and lack of access to secondary prevention interventions such as overdose education and naloxone distribution programs within BIPOC communities;^(20)(21)
• The lower availability of evidence-based treatment (particularly buprenorphine) for BIPOC and the continued experience of discrimination within treatment programs and systems;⁽²²⁾
• The unequal deployment of drug testing with markedly different consequences for BIPOC when their test results are positive;^(23)(24)
• The underrepresentation of BIPOC in scientific studies, thus yielding interventions that may not be culturally appropriate;^(25)(26) and
• Markedly different rates of incarceration despite national survey data that suggest that BIPOC and whites use drugs at similar rates.⁽²⁷⁾

The overcriminalization of drug use by BIPOC and disparate policing of BIPOC who use drugs is well documented.⁽²²⁾ The effects of this discrimination are devastating and lasting. Addiction medicine professionals are too often silent and accepting of a system that mandates inappropriate treatment.

Both racism and criminal-legal system involvement are traumatizing. Addiction medicine professionals have the opportunity to counteract that trauma in their practices through trauma-informed care.

The principles and practice of trauma-informed care – a strengths-based care delivery approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives ⁽²⁸⁾, ⁽²⁹⁾ – can promote a culture of safety, empowerment, and healing.⁽³⁰⁾, ⁽³¹⁾, ⁽³²⁾ Increasing the diversity of the addiction medicine workforce and staff of addiction medicine programs and practices can also help improve patient care, satisfaction, and outcomes and alleviate health disparities.⁽³³⁾, ⁽³⁴⁾, ⁽³⁵⁾, ⁽³⁶⁾ While these issues extend beyond addiction medicine, this statement focuses on steps that addiction medicine professionals and all health care professionals who treat patients with addiction can take to advance racial justice. Subsequent statements will address broader public health and social issues and make recommendations for broader policy and societal change.

Recommendations

The American Society of Addiction Medicine recommends:

1. Addiction medicine professionals should examine their own motivations, biases, and practices related to BIPOC to deliver equitable, compassionate, and anti-racism-informed⁽³⁷⁾ medical care to all patients. Research is needed to identify best practices for motivating and facilitating such an examination.
2. Addiction medicine professionals must lead medical practices and treatment programs that acknowledge and respond to patients’ experiences of racism by (a) trusting and respecting patients’ experiences through trauma-informed care, (b) assessing patients for social determinants of health, including those that are linked to racism, and connecting them with community resources, and (c) evaluating their medical practices based on staff diversity and BIPOC patient satisfaction and retention in treatment.
3. Addiction medicine professionals should develop proficiency⁽³⁸⁾ in, practice, and demonstrate leadership in trauma-informed care as well as structural competency, so that they can (a) understand patient experiences in the context of structural factors that influence their health; (b) intervene to address those structural factors, such as inequalities in law enforcement, housing, education, access to health care, and other resources, that put patients at risk for unhealthy substance use and addiction or limit their access to prevention, treatment and recovery supports; and (c) collaborate with community leaders and health professionals with humility and patience.⁽³⁹⁾
4. Providers of addiction medicine training in medical school, residency, fellowship and continuing medical education (CME) programs should review their curricula to identify gaps related to trauma-informed care, structural competency, and racial understanding. Clinical educators should develop and promote training courses grounded in trauma-informed care and structural competency to improve the outcomes of patients who are socially marginalized by virtue of their race, e.g., those who are identified more frequently by the criminal legal system due to disparate policing and then are referred or mandated to addiction treatment.
5. Addiction medicine professionals should advocate for policies that lead to a more diverse addiction treatment workforce and should seek opportunities to mentor BIPOC clinicians into the field. Robust funding should be made available and targeted for scholarships and loan repayment for BIPOC addiction medicine professionals.
6. Addiction medicine professionals should advocate for policies that ensure BIPOC at risk of, or with, addiction have equitable access to evidence-based prevention, early intervention, treatment, and harm reduction services. Further, addiction medicine professionals should advocate for policies that are designed to eliminate structural inequalities in social and economic factors that influence substance use and addiction (e.g., law enforcement practices and access to housing, education, and health care), as these social determinants of health contribute to health disparities between BIPOC and white people.
7. Addiction-related research should strive to include an equitable representation of BIPOC researchers and participants in study design, implementation, and dissemination of results. Addiction-related research should evaluate the impact of systemic racism on drug use; risk and protective factors for addiction; and access to prevention interventions, treatment and harm reduction options, and recovery support services. Clinical resources and recommendations should be designed with consideration of the broad social, political, and economic structures that affect health and illness. Community-based participatory research methods can help build trust between researchers and BIPOC given historical research practices.

Endnotes

Advancing Racial Justice in Health Care through Addiction Medicine

Purpose

This is the second in a three-part series of public policies on racial justice through which ASAM summarizes the evidence that systemic racism is a major social determinant of health⁽¹⁾ with profound, deleterious effects on the lives and health of Black, American Indian/Alaska Native, Hispanic/Latinx, Asian, Pacific Islander, and other racially and ethnically minoritized and disenfranchised people (hereinafter collectively referred to as Black, Indigenous, People of Color (BIPOC)).⁽²⁾,⁽³⁾ This series of policy statements is part of ASAM’s effort to recognize, understand, and then counteract the adverse effects of America’s pervasive, historical, yet continuing, systemic racism, specifically with respect to full-spectrum addiction care, including prevention, early intervention, harm reduction, diagnosis, treatment, and recovery.

The series’ first policy statement⁽⁴⁾ focuses on actions that addiction medicine professionals should take to tackle systemic causes of health disparities. It recognizes that many choices made by healthcare professionals, while not always the result of conscious or intentional racism, may nonetheless reflect biases that operate in the context of longstanding systems and policies that marginalize and exclude BIPOC.⁽⁵⁾ The corrective response must consist of conscious efforts to overcome these biases and unjust systems.

This second policy statement focuses on actions that healthcare professionals, healthcare systems, institutions, and organizations, professional medical entities, researchers, and health professional educators can take to help advance addiction medicine and its role in addressing health disparities for BIPOC. It highlights the longstanding role of the criminal legal system and child welfare in inappropriately assuming responsibility for, or otherwise interfering upon, clinical decisions for people with substance use disorders (SUD), with the most adverse consequences disproportionately affecting BIPOC. Finally, it highlights the need for clinicians and patients to take responsibility for shared decision making with respect to full-spectrum addiction care.

By illustrating how punitive responses have failed BIPOC who use substances, ASAM intends to demonstrate the urgent need for policy reforms that prioritize full-spectrum addiction care over punishment, reduction of stigma against all people who use substances, and enhancement of the health and well-being of all people who have the disease of addiction.

Background

As detailed below, BIPOC with SUD often do not receive evidence-based addiction care and are more likely than White people to be treated punitively by the criminal legal and child welfare systems as a result of substance use.⁽⁶⁾ To rectify this situation, groundbreaking change will be required within the criminal legal and child welfare systems, in addition to major reforms within healthcare systems, institutions, and organizations, professional medical entities, health professional education, and medical research and practices.

Substandard Care for BIPOC Who Use Substances

There is ample evidence of systemic racism within the U.S. healthcare system. In 2002, the Institute of Medicine concluded that “racial and ethnic minorities receive lower-quality health care than white people—even when insurance status, income, age, and severity of conditions are comparable.”⁽⁷⁾ Health care still has far to go to address these inequities. For example, a study published in 2022 found that Black patients were 2.5 times as likely as White patients to have a negative descriptor (such as ‘resistant’ or ‘noncompliant’) included in their health record.⁽⁸⁾

The situation for BIPOC is equally bleak in addiction medicine, where BIPOC are less likely than White people to receive the standard of care in a range of areas. Examples include:

• Black patients are less likely to receive medication for alcohol use disorder.⁽⁹⁾
• BIPOC are less likely to be offered the standard of care—particularly buprenorphine—to treat opioid use disorder (OUD).^(10-14)
• BIPOC are less likely to complete addiction treatment at least partly due to inequities in social determinants of health (SDoH) caused by structural racism, specifically, financial and housing instability.⁽¹⁵⁾
• BIPOC face more barriers than White individuals do in accessing harm reduction services.^(16-19)

Changes in the current situation—including the adoption of an explicitly antiracist⁽²⁰⁾ approach, and the development of more equitable institutions and social conditions—are needed to address these and other problems faced by BIPOC who use substances.⁽²¹⁾

Use of Punitive Systems Against BIPOC Who Use Substances

Overall, the United States’ use of punitive systems to address illicit substance use and SUD has been ineffective in addressing the nation’s overdose crisis, and larger policy changes—including an examination of appropriate penalties for personal drug use possession—are needed to reverse this approach. The impact of this failed approach has been felt most acutely by BIPOC.

A historically racialized, punitive approach to substance use in the United States has been weaponized against BIPOC, including the use of opium laws against Asian people, cannabis policy against Latinx people, and disparate cocaine sentencing laws against Black people.4 In addition, methadone treatment for OUD was authorized during a time of racialized “anti-crime politics,” which resulted in a highly-regulated, closed clinic system that emphasized regulatory compliance more than treatment access.⁽²²⁾,⁽²³⁾ Highly-detailed federal regulations that surround this specific medical practice have oriented it away from primary care⁽²⁴⁾ to the detriment of individualized patient care, and have contributed to racial health disparities among people with OUD.⁽²⁵⁾,⁽²⁶⁾ Indeed, today’s racially-patterned access to methadone and buprenorphine for OUD denies Black and Hispanic/Latinx communities equitable access to buprenorphine, which is a more flexible form of care. ⁽²⁷⁾ Finally, perhaps one of the most compelling data points is that although Black and White Americans sell and use drugs at similar rates, Black people in the United States are 2.7 times as likely to be arrested for drug-related offenses and 6.5 times as likely as White people to be incarcerated for drug-related crimes.⁽²⁸⁾,⁽²⁹⁾

In general, the criminal legal system has done a poor job providing evidence-based care to people with SUD.⁶ Fewer than 5% of people referred by the criminal legal system to specialty treatment programs for the treatment of OUD received standard of care medication.⁽³⁰⁾ In addition, very few carceral facilities offer medications for OUD, especially methadone or buprenorphine; people already treated with these medications are often forced to stop this life-saving therapy, suffer withdrawal, and risk overdose and overdose death. Disturbingly, this is happening against a backdrop of research indicating that individuals who are incarcerated are 129 times more likely to die from overdose within the first two weeks after release when compared to the general U.S. population – particularly from opioids.⁽³¹⁾ Given the disproportionate involvement with the criminal legal system, this low standard of care poses a particular risk for BIPOC.

Healthcare professionals have participated in providing substandard care within the criminal legal system by ceding control over the treatment plans to criminal legal system authorities who are not clinicians. For example, the criminal legal system has been shown to: exclude the use of methadone or buprenorphine as treatment for persons under community correctional control, or impose limits on their use;⁽³²⁾ mandate treatment from a limited pool of addiction treatment providers with whom the system contracts, regardless of the individualized needs or third-party insurance coverage of the incarcerated person;⁽³³⁾ and refuse to provide methadone or buprenorphine while a person is incarcerated.⁽³⁴⁾ Further, the National Drug Court Institute has found that “representation of African-American and Hispanic individuals in jails and prisons was nearly twice that of both drug courts and probation, and was also substantially higher among all arrestees for drug-related offenses.” ⁽³⁵⁾

Research has found, in addition, that clinicians are more likely to order drug tests for BIPOC,⁽³⁶⁾,⁽³⁷⁾ and positive drug test results can lead to negative consequences unrelated to health for BIPOC if disclosed by healthcare professionals to entities outside of health care.

Racial Inequities in Child Protective Services Response to Pregnant and Parenting People

Parental substance use is a frequent cause of referrals to child welfare, especially during pregnancy and during or following childbirth. More than one-third of out-of-home placements noted parental substance use as a contributing factor.⁽³⁸⁾ As currently structured, however, healthcare providers often employ a faulty, underlying assumption that substance use in itself is “reportable” even when the “substance” is opioid agonist treatment for OUD (methadone or buprenorphine). ⁽³⁹⁾ Most reports to child welfare occur for infants in the first year of life and originate from healthcare professionals.⁽⁴⁰⁾ Methods of screening⁽⁴¹⁾ have historically relied on urine drug testing,⁽⁴²⁾ and healthcare professionals often perceive reporting results as mandatory.⁽⁴³⁾ The practice of “test and report” has been decried as medically unethical and public health ineffective by the American College of Obstetricians and Gynecologists (ACOG), “The laws, regulations, and policies that require health care practitioners and human service workers to respond to substance use and substance use disorder in a primarily punitive way, require health care providers to function as agents of law enforcement.” ⁽⁴⁴⁾ In addition, child welfare reporting undermines patient trust, can discourage a pregnant person from seeking care for OUD for fear of child welfare involvement, contributes to provider moral injury, and worsens racial inequities.

There are marked racial inequities in the child welfare response,⁽⁴⁵⁾ from drug testing, to child welfare reporting, to foster placement, and to the termination of parental rights.⁽³⁹⁾,⁽⁴⁶⁾

Though Black children are 14% of the children in the United States, they represent 23% of children in foster care and are less likely to be reunified with their families.⁽⁴⁷⁾ Despite documented evidence that Black and White people have comparable rates of substance use, reports reveal that more Black than White infants have been reported to child welfare due to parental substance use.⁽⁴¹⁾

Antiracism Efforts Needed Elsewhere Within Health Care

Just as the criminal legal and child welfare systems have had disproportionately damaging effects on BIPOC, so have many of the structures built and operated by healthcare professionals and administrators. Reforms are needed within healthcare systems, health professional schools, clinical research, and healthcare practice to address and eliminate health inequities.

The effects of SDoH on patient outcomes—particular among BIPOC—have been well-documented.⁽⁴⁸⁾ Unfortunately, many clinicians and healthcare systems are unprepared to screen for SDoH among their patients and then take action based on the screening results due to inadequate resources.⁽⁴⁹⁾ In many cases, community-based organizations may be logical partners to work with healthcare institutions.⁽⁵⁰⁾ Unfortunately, many clinicians and healthcare systems are unprepared to screen for social determinants of health among their patients and then take action based on the screening results due to inadequate resources.

Reforms are needed throughout the clinical research enterprise to eliminate disparities. The construct of race is often applied inappropriately in clinical research; existing standards outline how researchers and journals should address this problem.⁽⁵¹⁾ Additionally, BIPOC are underrepresented in clinical trials, yielding interventions that may not be culturally appropriate.⁽⁵²⁾ Finally, other research has demonstrated that BIPOC researchers are less likely to receive National Institutes of Health funding than White researchers.⁽⁵³⁾,⁽⁵⁴⁾

Other scholarship has highlighted the inappropriate use of race in clinical algorithms put forward by clinical societies and healthcare systems used to make clinical care decisions. Not only may this unnecessarily inject issues of race in clinical care, but the inclusion of race in algorithms may direct additional resources to White patients and away from BIPOC. One recent review found examples of this occurring in clinical fields ranging from cardiology to nephrology to obstetrics.⁽⁵⁵⁾

The first document in this series proposed that addiction medicine providers should use trauma-informed care to help BIPOC overcome the trauma associated with racism and criminal legal system involvement.

The principles and practice of trauma-informed care—a strengths-based care delivery approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives ^(57)(58) –can promote a culture of safety, empowerment, and healing.^(58-60) This approach is relevant for all healthcare professionals.

Increasing the diversity of the medical workforce, including across addiction medicine programs and practices, can also help improve patient care, satisfaction, and outcomes and alleviate health disparities.^(61-65) According to the most recent data, less than 12% of physicians self-identified as Hispanic or Black, despite those two groups making up over 30% of the United States population. Trends among medical students show minimal, if any, improvements in medical school diversity.⁽⁶⁶⁾ Latinx-identified individuals comprise 5.5% of medical school faculty, Black or African American individuals comprise 3.6%, and American Indian or Alaska Native individuals comprise 0.2% of medical school faculty.⁽⁶⁷⁾

Recommendations

Recommendations for Reducing Criminal Legal System Influence on Addiction Care:

1. Healthcare professionals should support the elimination of policies that restrict the use of evidence-based addiction treatment for people with SUD who are in carceral settings or under community correctional control. In particular, decisions which involve treatment plans—including the type, duration, choice of medication, and level of care—should be made by healthcare professionals rather than non-clinical authorities in criminal legal systems and should be consistent with standards of care. Given the disproportional involvement of BIPOC with criminal legal systems, such changes are critical to address inequities and help BIPOC receive evidence-based addiction care.
2. Healthcare professionals should support equitable practices in drug courts. Consistent with ASAM policy,⁽³²⁾ reforms to drug courts should provide individuals with equitable access to evidence-based treatment for SUD, including all FDA-approved addiction medications available in the community or via telehealth, and prohibit interference of non-clinicians with the clinician-patient relationship. Drug court reforms must address inequities within the drug court system.
3. Healthcare professionals should support legislative and regulatory changes to enhance harm reduction efforts, including overdose prevention sites, syringe service programs, exploring other medications for SUD, and drug checking services. Healthcare professionals should be able to refer people who use substances for evidence-based, harm reduction interventions or use those interventions as a standard part of patient care. Healthcare professionals should support equitable access to all evidence-based harm reduction services for people who need them, with a specific effort to increase the engagement of BIPOC communities in the development of such services.
4. Healthcare professionals should use caution in ordering drug tests (toxicology) and sharing clinical drug testing (toxicology) results with entities outside of health care, including those in the criminal legal and child welfare systems. The goals of healthcare and criminal legal and child welfare systems do not always align. Healthcare professionals should educate patients on confidentiality and the purpose of the external request and obtain informed consent before making any disclosures.⁽⁶⁸⁾

 

Recommendation for Reducing Child Welfare System Influence on Addiction Care

5. Healthcare professionals should support the removal of legal mandates and local practice standards to report pregnant or parenting people to child protective services or other government agencies on the sole basis of substance use or SUD. Such requirements can be harmful and discourage people from seeking addiction treatment and prenatal care, which can lead to worse health outcomes for pregnant person, parent, and infant.

 

Recommendations for Healthcare Systems, Institutions, and Organizations, Professional Medical Entities, and Researchers

6. Efforts to increase diversity within the healthcare workforce are critical to improving addiction care. Organizations and institutions within healthcare systems must act with the understanding that there are structural implications to fostering a sense a belonging⁽⁶⁹⁾ for BIPOC patients who use substances and prioritize garnering points of view from a diverse group, not a select few.⁽⁶⁹⁾ To improve addiction care and research, healthcare systems must hire and compensate individuals from the communities that they serve. These systems demonstrate the value of diversity when they listen to and implement recommendations from diverse sources and mentor and promote diverse individuals to leadership positions within the system.
7. Healthcare systems should expand the range of evidence-based services they provide in order to meet the needs of BIPOC with SUD, including the initiation of medication for OUD (e.g. buprenorphine) and offering naloxone for overdose reversal in emergency departments, hospitals, other urgent care settings, and primary care settings. Under certain circumstances, failure to do so may be a violation of federal law, including the Civil Rights Act.⁽⁷⁰⁾
8. All healthcare settings should consider and address social determinants of health—including housing, education, transportation, employment, and racism itself—as part of a patient’s comprehensive treatment and recovery. Providers should consider open access scheduling, mobile services, community-based sites, and expansion of telehealth or other remote service deliveries, and working with local community-based organizations⁽⁷¹⁾ to help address those needs.
9. All healthcare settings—along with other professional medical entities—should assess their care systems, clinical guidelines and algorithms,⁽⁷²⁾ and policies through a health equity and racial justice lens and revise them as needed. For example, new care approaches, such as telemedicine, may unintentionally propagate inequities if not implemented appropriately.⁽⁷³⁾,⁽⁷⁴⁾
10. In medical journals, racism must be interrogated as a critical driver of racial health disparities in addiction medicine,⁽⁵¹⁾ ensuring that clinical research related to addiction is reformed to be antiracist. BIPOC with lived experience should be better represented as part of clinical trials, including as part of the team conceptualizing, conducting, analyzing and interpreting, and disseminating the clinical research.^(52)(75) Research thus conducted can be applied to the explicit end goal of translating the findings into improved clinical practice for BIPOC who use substances. Efforts focused on community engagement, recruitment, and retention of a diverse pool of research participants is imperative to achieve this goal.⁽⁶⁹⁾
11. In addition to implementing needed changes to address healthcare inequities and ensure that BIPOC have equal access to evidence-based addiction care, healthcare institutions should regularly assess whether their antiracist policy interventions are having their desired effect. Healthcare systems should involve BIPOC staff, BIPOC members of communities, particularly those BIPOC with lived experience, and BIPOC researchers as part of this process.⁽⁶⁹⁾

 

Recommendations for Healthcare Professionals and Their Medical Practices

12. Healthcare professionals should advocate for substance use to be addressed as a health issue, and addiction as a treatable, chronic medical disease and not be addressed by the criminal legal system with arrest and incarceration. The criminal legal system should not be used to interfere with, or influence, the assessment, diagnosis, or treatment decisions of those with SUD. Too often, these clinical decisions have been relinquished by healthcare professionals to the criminal legal system. Given that the criminal legal system has had inequitably detrimental effects on BIPOC, reforms within this system are particularly needed to achieve racial justice.
13. Healthcare professionals should regularly examine their practices and whether they deliver health care services in a biased way. When biases are identified, action should be taken to counter biased practices in order to deliver equitable, compassionate and anti-racism-informed⁽⁴⁾ addiction care to all people who need it.
14. Healthcare professionals must lead medical practices that acknowledge and respond to experiences of racism of BIPOC patients who use substances by (a) trusting and respecting those patients’ experiences through trauma-informed care, (b) assessing those patients for social determinants of health, including those that are linked to racism, and connecting them with community resources, and (c) evaluating their medical practices based on staff diversity and inclusion as well as patient satisfaction and retention in treatment among their BIPOC patients with SUD.
15. Healthcare professionals should develop proficiency⁽⁴⁾ in, practice, and demonstrate leadership in trauma-informed care for BIPOC patients who use substances as well as structural competency, so that they can (a) understand those patient experiences in the context of structural factors that influence their health; (b) intervene to address those structural factors, such as inequalities in law enforcement, housing, education, access to health care, and other resources, that put patients at risk for unhealthy substance use and addiction or limit their access to addiction prevention, treatment and recovery supports; and (c) collaborate with community leaders with humility.⁽⁴⁾,⁽⁷⁶⁾
16. Preventing, screening for, assessing and intervening regarding SUD should be considered an essential part of general medical practice. In working with BIPOC who use substances, this includes healthcare professionals having the skills and training to prescribe a range of treatment approaches, including addiction medications.

 

Recommendations for Healthcare Professional Education and Training

17. Providers of training in medical school, residency, fellowship and continuing medical education (CME) programs should review their curricula to identify gaps related to addiction care, trauma-informed care, structural competency, and racial understanding. Clinical educators should develop and promote addiction medicine training courses grounded in trauma-informed care and structural competency to improve the outcomes of patients who are socially marginalized by virtue of their race, e.g., those who are identified by the criminal legal system due to disparate policing and then are referred or mandated to addiction treatment. Education and training of healthcare professionals on addiction care should be evaluated to ensure content aligns with the principles of cultural sensitivity and inclusion, health equity, and racial justice.
18. Healthcare professionals should advocate for creation and implementation of policies that lead to a more diverse clinical workforce equipped to treat SUD⁽⁶⁹⁾ and should seek opportunities to mentor BIPOC physicians and other clinicians. The outcomes of these policies should be regularly assessed to ensure that they are achieving their stated goals. Robust funding should be made available and targeted for scholarships and loan repayment for BIPOC healthcare professionals who treat SUD.

Endnotes

Racial Justice Beyond Health Care: Addressing the Broader Structural Issues at the Intersection of Racism, Drug Use, and Addiction

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Purpose

Stigma and racism at the societal level, driven and reinforced by culture and laws, are root causes of health inequities that affect people who use certain drugs or struggle with addiction, with particularly acute consequences for people of color. This policy statement considers the role of various structural conditions on health and well-being and includes recommendations to address the broader structural issues at the intersection of racism, drug use, and addiction. Such recommendations are expected to create systems that benefit all people.

Background

In this final public policy statement of a three-part series on advancing racial justice in the context of addiction medicine, ASAM continues its analysis of systemic racism as a social determinant of health that disproportionately damages the health and lives of Black, Indigenous, and People of Color (“BIPOC”) who use substances or have substance use disorder (SUD). The first statement in this series set forth ASAM’s recommendations for addiction medicine professionals to improve the quality of full-spectrum addiction care delivered to BIPOC who need SUD services.(1) The second statement broadened the focus of the analysis to include actions that healthcare systems, institutions, organizations, professional medical entities, researchers, and health professional educators should take to reduce the detrimental impact of systemic racism on BIPOC who use substances or have SUD.(2) In this third statement, ASAM describes the role of structural conditions that create inequities for people who use illegal substances or have SUD, with particularly acute consequences for BIPOC.

Below, ASAM describes how structural stigma related to SUD and to race create health inequities. That description is followed by policy recommendations that seek to address structural issues that negatively impact health and well-being, including recommendations related to decriminalization. It is important to note upfront, however, that the decriminalization recommendations in this statement focus on the elimination of criminal and onerous civil penalties for drug and drug paraphernalia possession for personal use. They intentionally do not include designing a framework for regulated access to currently illegal drugs for non-medical use given that even slight changes in the legal supply of certain drugs can pose great risk of increased use and harm, especially to marginalized people, and the current gaps in drug policy research.

How Structural Stigma and Racism Similarly Function to Define Cultural Views of People Who Use Illegal Drugs or Have SUD

Stigma is a structural determinant of health and a fundamental cause of health inequities that affects marginalized people, including people with SUD and BIPOC.(3) Stigma is often narrowly conceptualized as occurring between two people but, like racism, is actually multilevel and multifaceted.(4),(5) Interpersonal stigma is how individuals more commonly experience disempowerment and discrimination on a day-to-day basis.

Conceptualized as a structural determinant, stigma represents a collective environment created through labeling, stereotyping, isolating, and removing power and status from a group of people through policies and practice. These power structures create differential access to social and material resources that can influence health and wellness, like housing, education, social support, and employment opportunities.

While some may contend that drug-related stigma helpfully discourages drug use, structural stigma related to SUD is more complex,(6) and perpetuating stigma is distinct from improving preventive risk and protective factors.(7) Moreover, the negative consequences of stigma far outweigh any positives.(6)

For more than a century, drug policy in the United States of America (U.S.) has labeled possession of certain drugs for personal use as a crime, thereby designating people who use those drugs (and people who engage in drug use due to a chronic illness) as deviants(8) and criminals. The label of “criminal” carries with it negative stereotypes, perceived license for punishment and social isolation, ongoing discrimination and disenfranchisement, and “us-versus-them” narratives. (3) The criminal designation of possession of certain drugs for personal use justifies the “othering” of people who use those drugs.(9) Overly punitive drug policies, including drug paraphernalia laws, have exacted substantial collateral harm upon the lives of people who use illegal drugs, the functioning of their families, and their broader communities.(10), (11) Indeed, the U.S. Government Accountability Office noted at least 641 collateral consequences of a nonviolent drug conviction that include exclusions from employment, housing, loans, licensure, civic participation, family rights, and more. (12) While the perception of deviance of certain drug use may have, in some cases, preceded the assignment of criminality, it is through policies and practice that society perpetuates this stigma.

Like stigma, structural racism functions through othering mechanisms and transcends the prejudicial beliefs and discriminatory behavior of any one person. Federal, state, and local policies have propagated, promulgated, and reinforced racial stereotypes (13) and restricted access to housing, education, employment, and other social and material goods through state-sponsored housing discrimination that led to residential segregation and present-day concentrated poverty. (14)

Racial covenants(15) – where Black individuals and other marginalized groups were excluded from purchasing homes – and structural forms of discrimination against BIPOC seeking fair access to resourced communities have had a lasting impact on the U.S.(14)

Residential segregation persists today such that racially minoritized people are more likely to experience concentrated poverty, greater negative exposures from police surveillance, higher housing cost burden, limited financial safety nets, and lack of economic opportunity, which creates challenges in meeting basic needs for all individuals, but especially those challenged with a chronic illness.(14) In addition, these unjust conditions unfairly expose youth to adverse childhood experiences associated with SUD,(16) further perpetuating the impact of decades-old structural determinants into the next generation.

Many BIPOC communities are still experiencing the damaging effects of the “wars” on crime, and then on drugs, which diverted needed resources from these communities and into the law enforcement apparatus, thus eroding social determinants of health for those populations.(17) Although the letter of the laws do not target BIPOC, U.S. drug laws are a form of structural racism today because the laws are inequitably implemented(1)(2) in ways that reinforce power structures, reduce access to opportunity, and amplify disadvantage.(18) For example, enforcement and consequences of drug paraphernalia laws fall disproportionately on BIPOC communities and are the primary legal barrier to the uptake of evidence-based harm reduction interventions that prevent the spread of disease and reduce drug overdoses. (19)

How Stigma Related to Race and Certain Drugs Changes Structural Conditions for People Who Use Those Drugs or Have SUD

The structural stigma and racism that embodies the othering processes have spawned policy initiatives that continue to have tangible, disproportional, deleterious consequences for BIPOC who use illegal drugs or have SUD and for their families and communities. Dating back to 1914, with the enactment of the Harrison Narcotic Tax Act, and moving through the Controlled Substances Act of 1970, the Sentencing Reform Act of 1984, and the Anti-Drug Abuse Act of 1986 – U.S. drug policy has reflected and exacerbated the othering of BIPOC that was the deliberate intent of redlining policies, Jim Crow laws, and mass incarceration.(20)

One of many examples of the enduring legacy of the Anti-Drug Abuse Act of 1986 is that in 2022, people who use certain drugs can be – and frequently are – denied access to public housing because of a history of criminal legal system involvement with 20-year or even lifetime lookback periods, or they can be evicted from housing because of suspected illegal drug use of any individual within the household.(21)

The U.S. Department of Housing and Urban Development (HUD) guidance states that blanket policies refusing housing solely based on criminal history are likely a violation of the Fair Housing Act of 1968 due to the disparate impact on racially minoritized people.(22) Structural changes are needed at the federal level to reverse the harms of historical housing policies and hold local housing authorities and private and public housing providers accountable for following the HUD guidance and equitable practices.(22)

Even the Drug Addiction and Treatment Act of 2000 (DATA 2000), which was an effort to medicalize and normalize treatment for opioid use disorder (OUD), has fallen victim to the social landscape of the U.S. drug policy response. Though DATA 2000 allowed certified physicians to prescribe buprenorphine in their own offices, it failed to address criminalization, the restriction of methadone to opioid treatment programs (OTPs), or other variables limiting geographic accessibility to treatment for OUD. It resulted in a “two-tier” treatment system,(23) with ultimately greater accessibility of office-based buprenorphine treatment for White people with OUD.(24)

Racial inequities also exist in child protection system responses to pregnant and parenting people, particularly when substance use is involved as the cause of removal. Despite similar rates of illegal drug use among Black and White individuals, (25) Black families are more likely to be tested for substances and reported to the child protection system, with healthcare professionals serving as the primary source of reports to the child protection system.2 Black families are more likely to have a child removed (despite being assessed at a lower risk) for longer periods of time, to undergo family separation, and are less likely to be reunified.(26) In states that criminalize prenatal substance use, the reunification of Black families is even less likely.(27)

The Present-Day Manifestations of Race-, Drug-, and SUD-Related Stigma

In the U.S., racial tropes and exaggerations or outright fabrications about the harms of certain drugs have been used to stoke fear among the public and promote drug policies that demoralize and disenfranchise people who use those drugs. Few broad-reaching attempts have been made in earnest to correct the excessively criminal response to SUD or the severe inequities in drug law implementation, because drug policies have been aligned with dominant cultural attitudes that associated crime and drugs with Blackness, and certain drug use with criminality.(28) However, such punitive drug policies have been criticized more recently; it may be no coincidence that the shift occurred as the public face of addiction began to look more White.

Starting about two decades ago, the U.S. has been in the throes of an opioid overdose crisis,(29) which has often been characterized by the media as a problem for White rural America.(30) Going against decades of criminal legal policies, rhetoric such as “we are not going to arrest our way out of this” began to surface as dominant views responded to the cognitive dissonance induced by replacing the stereotype of a person that uses certain drugs. What once was easily identified as “them” when the media overrepresented Black faces in drug-related stories,(31) now looked more like “us.”(32)

Typical of the “White exceptionalism” of drug war politics, shifts in the deviancy narratives emerged.(33) Suddenly, harsh penalties became less palatable to the American public, which increasingly adopted the previously dismissed notion of addiction as a medical condition for which affected individuals deserved compassion, understanding, and effective treatment rather than vilification, scorn, and incarceration.

2020 marked a peak in the collective awareness and dialogue of the American public regarding racial justice. The aftermath of George Floyd’s murder at the hands of law enforcement serves as a compelling example of how SUD stigma and structural racism can intersect, amplify, and override progress if either social driver is left unaddressed. In the days and months following George Floyd’s death, his history of drug use emerged in public rhetoric as a justification for his brutal murder, as if the use of drugs somehow disqualified him from due process.(34)(35) Much of America defaulted to once again compartmentalizing inhumanity, reserving justice and compassion only for “us” when the face of the person who used certain drugs was Black. Structural solutions to address race-, drug-, and SUD-related stigma are needed for lasting change.

Advancements in Structural Change

Drug policy in the U.S. has served as the foundation of the legitimized oppression of both BIPOC and people with SUD. Because SUD stigma and structural racism exist at the societal level and persist beyond any interpersonal encounters, structural solutions are needed. Reducing the criminal legal consequences of some or all drug possession for personal use is an emerging strategy for reducing stigma and advancing racial justice. Scholarship examining changes in public opinion on gay marriage support that changes in policy can rapidly shift, albeit not eliminate, stigma.(36)

In fact, laws that provide protections to stigmatized groups may positively impact the mental health and general health of those provided protection.(37) While SUD and racial stigma can be helped by policies that attack the racist legacy of prohibition, more work must be done to complement structural change and challenge social ideologies.(38)

Delinking criminality from drug and drug paraphernalia possession for personal use – while offering access to treatment and supportive services - will help reduce imprisonment and its collateral consequences, which serve as a tool for BIPOC oppression.

In 2019, over 1.5 million people in the U.S. were arrested for drug offenses, more than any other category of crime, and nearly 90% of those arrests were for drug possession.(39) Moreover, research shows that U.S. states with higher rates of drug imprisonment do not experience lower rates of self-reported drug use.(40)

However, elimination of such criminal penalties is not likely to eliminate racism and systemic disinvestment in BIPOC communities. Societal stigma can still persist and compensatory policies and street-level politics can counteract progress.(41) For example, while arrests have decreased following cannabis policy reform, substantial racial differences in rates of arrest still exist, and in some states,(42) arrests increased for drugs other than cannabis. Similar research on drug court and diversion programs suggest that BIPOC benefit less from these drug policy reforms.(43)

While some may highlight that such decriminalization efforts will not address the nation’s toxic, illegal drug supply, ASAM recognizes that any changes in laws that would increase legal access to currently illegal drugs would need to be carefully thought out, implemented gradually and sequentially, and scientifically evaluated at each step of implementation.

Additionally, given that the current U.S. political environment does not seem well-poised to take quick action to rein in for-profit interests, as well as the risks associated with any significant increase in unhealthy drug use and the current gaps in drug policy research(44), there is currently no path for firm and sustainable regulation to prevent consumer expansion and exploitation, of which BIPOC are historically among the most common targets. (45)(46) By way of contrast, evidence from Portugal suggests that eliminating the criminality of drug possession for personal use, as part of a larger set of public health reforms, investments, and norms, can lead to improvements in health without offering legal means of obtaining regulated drugs for non-medical use.(47)

In 2020, Oregon passed Measure 110, which decriminalized possession of scheduled substances for personal use and invested in expanding access to services. While it may be too soon to evaluate Oregon’s approach, and such evaluations must endeavor to ask the right research questions,(48)(49) the experience of Portugal and other decriminalization initiatives showcase the value of therapeutic responses to drug possession for personal use.(47)(50) However, eliminating criminal penalties for drug possession for personal use is not sufficient for addressing the overdose crisis, as communities need sufficient capacity for timely delivery of non-compulsory clinical, social, and economic services with humane accountability.(51)

Importantly, drug policy reforms must not only eliminate the overreliance on criminal law but must also promote reparative justice – strategies that seek to repair the harms caused by decades of overly punitive drug policies and hundreds of years of state-sponsored discrimination against BIPOC.

Restorative strategies include policies such as the 2014 Clemency Initiative,(52) appropriate expungement, and financial investments in social determinants of health,(53) particularly targeting communities heavily impacted by the drug war.(54)

The drug war has been wielded as a tool of oppression against people with SUD and BIPOC. For over a century, investments have been made in ineffective strategies that have cost far too many lives. Reparative investments and structural policy changes are crucial for addressing the root causes of health inequities.

Recommendations

1. ASAM supports shifting the nation’s response to personal substance use away from assumptions of criminality towards health and wellness; BIPOC disproportionately bear the brunt of criminal legal responses to personal drug use, notwithstanding that White people use illegal drugs at similar rates.(47)
   1. Policymakers should eliminate criminal and onerous civil penalties for drug and drug paraphernalia possession for personal use as part of a larger set of related public health and legal reforms designed to improve carefully selected outcomes. (55) In the interest of harm reduction, policymakers should also eliminate criminal penalties for the manufacture and delivery of drug paraphernalia. Those decriminalization efforts should (i) include consideration of expungement of records of such prior offenses, so that people do not remain marginalized for them and (ii) prioritize eliminating the over-policing of BIPOC who use illegal drugs and racial disparities in related civil enforcement. Concurrently, policymakers should support robust policies and funding that facilitate people’s access to evidence-based prevention, early intervention, treatment, harm reduction, and other supportive services – with an emphasis on youth and racially and ethnically minoritized people – based on individualized needs and with availability in all communities.
   2. Policymakers should consider new clemency efforts that encourage people who are incarcerated in federal or state prison for nonviolent drug offenses – many of whom are BIPOC(42) – to petition authorities for appropriate sentence commutations or reductions.
   3. Federal lawmakers should pass legislation that would eliminate the federal crack and powder cocaine sentencing disparity and apply it retroactively to those already convicted or sentenced.
   4. Policymakers should support robust investments in research efforts that aim to evaluate alternative public health approaches to drug use, with a focus on different types of drug policies, laws, and law enforcement practices.(44)(56-58)
   5. The criminal legal system should not be used to interfere with, or influence, the assessment, diagnosis, or treatment decisions of those with SUD. Given that the criminal legal system has had inequitably detrimental effects on BIPOC, reforms within this system are particularly needed to achieve racial justice.
   6. Evidence-based addiction care, including the use of medications for addiction treatment, should be available to all in need, including people in prisons, jails, drug courts, child protection systems, or on probation or parole. Engaging in addiction treatment should not be a precondition for people who use illegal drugs or have SUD accessing other medical care or support services, including housing.
2. ASAM supports policies and programs that help address underlying structural and social determinants of addiction; such policies and programs are critical to advancing racial justice and improving access to high-quality addiction care for all people, especially BIPOC.
   1. Policymakers should support interagency collaborations and cost-effective programs that address social determinants of addiction(59) – with a particular focus on determinants that impact racially and ethnically minoritized people.
   2. Policymakers should eliminate drug conviction bans(60) and drug testing requirements(61) for public assistance programs, such as the Supplemental Nutrition Assistance Program and the Temporary Assistance for Needy Families program, and for programs providing financial aid for education.
   3. Policymakers should end evictions and remove housing bans based solely on nonviolent, drug-related activities and support policies that promote the safety and well-being of all people.(62)
   4. Policymakers should implement universal health care coverage that will support equitable access to evidence-based or evidence-informed addiction care for all, regardless of ability to pay. Initial federal reforms should include expanding Medicaid and Medicare coverage to include people who are in carceral settings or under community correctional control(63) and who are otherwise eligible.
   5. Policymakers should ensure that existing mental health and addiction parity laws are vigorously enforced and support federal policies that fully extend mental health and addiction parity and benefits to Medicare, all of Medicaid, and TRICARE. (64)
   6. Accreditation and licensing bodies should work towards improving accountability for evidence-based, patient-centered, and culturally competent addiction care that includes addressing social determinants of addiction.
3. ASAM supports policies and programs that equip addiction medicine and other professionals, as well as people with lived experience, with the data, knowledge, and skills that are necessary to engage in effective advocacy for dismantling structural racism and advancing racial justice and health equity for all people.
   1. Philanthropic organizations and persons should invest in advocacy infrastructures and organizations that can advance racial justice in addiction care.
   2. Training programs for addiction medicine professionals should review their curricula to identify gaps related to structural competency, racial understanding, and advocacy. Clinical educators should develop and promote addiction medicine training courses that communicate the impact of stigmatizing language on people with SUD, the necessity of harm reduction tools and interventions, and the benefits of addiction medications.
   3. Policymakers and program developers should engage people with lived experience with substance use in the development of policy and services related to addiction and its social determinants, and the positive contributions of people with lived experience should be compensated and recognized.
   4. Public health agencies should report and widely disseminate data related to substance use and SUD by race and ethnicity and monitor for improved, equitable outcomes.

Endnotes