Faculty Bibliography

BACKGROUND:Black clients in substance use disorder (SUD) treatment are associated with the lowest successful completion and substance use reductions. More work is needed to identify specific factors that support successful recovery of Black clients. METHODS:Data from U.S. outpatient SUD treatment facilities receiving public funding from 2015 to 2019 were analyzed (N = 2239,197). Primary analyses consisted of Black clients (n = 277,726) reporting admission and discharge substance use frequency. Multiple logistic regression was used to predict substance use frequency improvement from Black client demographic, recovery capital, treatment characteristics, and state. Disparities were compared between Black and non-Black clients. RESULTS:The overall Black client improvement percentage was 46.95%. Mutual-help group attendance and Length of Stay demonstrated clinically meaningful effect sizes controlling for all other variables and state. Attending mutual-help groups 8-30 times per month (State aOR = 2.54, 95% CI = 2.43, 2.64) and outpatient treatment stays of 4 months or more (State aOR = 2.50, 95% CI = 2.44, 2.56) were factors supporting Black client improvement. Importantly, states are associated with disparate Black client risk differences and only South Dakota had greater Black improvement (RD = 6.35, 95% CI = 1.00, 11.71). CONCLUSIONS:Black client factors supporting substance use improvement include ancillary mutual-help group attendance and increased treatment retention. These factors may be more critical in states with larger Black improvement disparities. In general, treatment providers increasing access to mutual-help groups, and adjusting program inclusiveness and motivational factors for retention, would make strides in increasing improvement outcomes for Black clients.

BACKGROUND/UNASSIGNED:Black patients seeking addiction care experience poorer treatment access, retention, and outcomes when compared to White counterparts. Black patients may have elevated group-based medical mistrust, which has been associated with poorer health outcomes and increased experiences of racism across multiple healthcare contexts. The relationship between group-based medical mistrust and expectations for addiction treatment among Black individuals remains untested. METHODS/UNASSIGNED:A total of 143 Black participants were recruited from two addiction treatment centers in Columbus, Ohio. Participants completed the Group Based Medical Mistrust Scale (GBMMS) and answered questions related to expectations of addiction treatment. Descriptive analysis and Spearman's rho correlations were performed to assess for relationships between group-based medical mistrust and expectations of care. RESULTS/UNASSIGNED:Group-based medical mistrust in Black patients was associated with self-reported delay in accessing addiction treatment, anticipation of racism during addiction treatment, non-adherence and discrimination-precipitated relapse. However, non-adherence to treatment was least strongly correlated with group-based medical mistrust demonstrating an opportunity for engagement. CONCLUSION/UNASSIGNED:Group-based medical mistrust is associated with Black patients' care expectations when seeking addiction treatment. Use of the GBMMS within addiction medicine to address themes of mistrust in patients, and potential biases in providers, may improve treatment access and outcomes.

The Half-Century long problem of addiction treatment disparities. We cannot imagine addressing disparities in addiction treatment without first acknowledging and deconstructing the etiology of this inequity. This article examines the history of addiction treatment disparities beginning with early twentieth-century drug policies. We begin by discussing structural racism, its contribution to treatment disparities, using opioid use disorder as a case study to highlight the importance of a structural competency framework in obtaining care. We conclude by discussing diversity in the workforce as an additional tool to minimizing disparities. Addiction treatment should be aimed at addressing care delivery in the context of the social, economic, and political determinants of health, which require appreciation of their historical origins to move toward equitable treatment.

Community mental healthcare around the world has been strained as people need more help and experience more barriers to access due to COVID-19. The rapid shift to telehealth services necessitated by the pandemic has made these difficulties even more pronounced. While this transition presented challenges for nearly every healthcare system, it has proven especially difficult for low resource settings such as community health centers. This article is a critical observational study of the care transformation of a state-funded safety net psychiatric system responding to the clinical needs of patients during the COVID-19 pandemic. By discussing the challenges, opportunities, and creative solutions for staff and patients, the article highlights the new importance of technology and adaptability in clinical care and outlines clear recommendations to ensure vulnerable populations do not fall into the "digital divide."

As overdose mortality is spiking during the COVID-19 pandemic, few race/ethnicity-stratified trends are available. This is of particular concern as overdose mortality was increasing most rapidly in Black and Latinx communities prior to the pandemic. We used quarterly, age-standardized overdose mortality rates from California to assess trends by race/ethnicity and drug involved over time. Rates from 2020 Q2-Q4 were compared to expected trends based on ARIMA forecasting models fit using data from 2006 to 2020 Q1. In 2020 Q2-Q4 overdose death rates rose by 49.8% from 2019, exceeding an expected increase of 11.5% (95%CI: 0.5%-22.5%). Rates significantly exceeded forecasted trends for all racial/ethnic groups. Black/African American individuals saw an increase of 52.4% from 2019, compared to 42.6% among their White counterparts. The absolute Black-White overdose mortality gap rose from 0.7 higher per 100,000 for Black individuals in 2018 to 4.8 in 2019, and further increased to 9.9 during the pandemic. Black overdose mortality in California was therefore 34.3% higher than that of White individuals in 2020 Q2-Q4. This reflects growing methamphetamine-, cocaine-, and fentanyl-involved deaths among Black communities. Growing racial disparities in overdose must be understood in the context of the unequal social and economic fallout from the COVID-19 pandemic, during which time Black communities have been subjected to the dual burden of disproportionate COVID-19 deaths and rising overdose mortality. Increased investments are required to ameliorate racial/ethnic disparities in substance use treatment, harm reduction, and the structural drivers of overdose, as part of the COVID-19 response and post-pandemic recovery efforts.

BACKGROUND:Racial and ethnic minorities face disparities in access to health care. Culturally competent care might lessen these disparities. Few studies have studied the patients' view of providers' cultural competence, especially in psychiatric care. We aimed to examine the associations of race, ethnicity, and mental health status with patient-reported importance of provider cultural competence. METHODS:Our retrospective, population-based, cross-sectional study used data extracted from self-reported questionnaires of adults aged at least 18 years who participated in the US National Health Interview Survey (NHIS; 2017 cycle). We included data on all respondents who answered supplementary cultural competence questions and the Adult Functioning and Disability survey within the NHIS. We classified participants as having anxiety or depression if they reported symptoms at least once a week or more often, and responded that the last time they had symptoms the intensity was "somewhere between a little and a lot" or "a lot." Participant answers to cultural competency survey questions (participant desire for providers to understand or share their culture, and frequency of access to providers who share their culture) were the outcome variables. Multivariable ordinal logistic regressions were used to estimate adjusted odds ratios (aORs) for the outcome variables in relation to sociodemographic characteristics (including race and ethnicity), self-reported health status, and presence of symptoms of depression, anxiety, or both. FINDINGS:3910 people had available data for analysis. Mean age was 52 years (IQR 36-64). 1422 (39·2%, sample weight adjusted) of the participants were men and 2488 (60·9%) were women. 3290 (82·7%) were White, 346 (9·1%) were Black or African American, 31 (0·8%) were American Indian or Alaskan Native, 144 (4·8%) were Asian American, and 99 (2·6%) were Mixed Race. 380 (12·5%) identified as Hispanic ethnicity and 3530 (87·5%) as non-Hispanic. Groups who were more likely to express a desire for their providers to share or understand their culture included participants who had depression symptoms (vs those without depression or anxiety symptoms, aOR 1·57 [95% CI 1·13-2·19], p=0·008) and participants who were of a racial minority group (Black vs White, aOR 2·54 [1·86-3·48], p=0·008; Asian American vs White, aOR 2·57 [1·66-3·99], p<0·001; and Mixed Race vs White, aOR 1·69 [1·01-2·82], p=0·045) or ethnic minority group (Hispanic vs non-Hispanic, aOR 2·69 [2·02-3·60], p<0·001); these groups were less likely to report frequently being able to see providers who shared their culture (patients with depression symptoms vs those without depression or anxiety symptoms, aOR 0·63 (0·41-0·96); p=0·030; Black vs White, aOR 0·56 [0·38-0·84], p=0·005; Asian American vs White, aOR 0·38 [0·20-0·72], p=0·003; Mixed Race vs White, aOR 0·35 [0·19-0·64], p=0·001; Hispanic vs non-Hispanic, aOR 0·61 [0·42-0·89], p=0·010). On subgroup analysis of participants reporting depression symptoms, patients who identified their race as Black or African American, or American Indian or Alaskan Native, and those who identified as Hispanic ethnicity, were more likely to report a desire for provider cultural competence. INTERPRETATION:Racial and ethnic disparities exist in how patients perceive their providers' cultural competence, and disparities are pronounced in patients with depression. Developing a culturally competent and humble approach to care is crucial for mental health providers. FUNDING:None.