Faculty Bibliography

Health inequities stem from systematic, pervasive social and structural forces. These forces marginalize populations and create the circumstances that disadvantage these groups, as reflected in differences in outcomes like life expectancy and infant mortality and in inequitable access to and delivery of health care resources. To help eradicate these inequities, physicians must understand racism, sexism, oppression, historical marginalization, power, privilege, and other sociopolitical and economic forces that sustain and create inequities. A new educational paradigm emphasizing the knowledge, skills, and attitudes to achieve health equity is needed.Systems-based practice is the graduate medical education core competency that focuses on complex systems and physicians' roles within them; it includes topics like multidisciplinary team-based care, patient safety, cost containment, end-of-life goals, and quality improvement. This competency, however, is largely health care centric and does not train physicians to engage with the complexities of the social and structural determinants of health or to partner with systems and communities that are outside health care.The authors propose a new core competency centered on health equity, social responsibility, and structural competency to address this gap in graduate medical education. For the development of this new competency, the authors draw on existing, innovative undergraduate and graduate medical pedagogy and public health, health services research, and social medicine frameworks. They describe how this new competency would inform graduate medical education and clinical care and encourage future physicians to engage in the work of health equity.

Despite available treatment options for addiction, there remains an abysmal uptake of treatment initiation and engagement among varying communities. The existing treatment gap is based on historical occurrences, including discriminatory drug policies that have targeted communities of color with addiction. The current opioid epidemic and differential treatment therein exemplifies the severity of the existing disparity in addiction treatment, highlighting barriers such as institutionalized racism and vulnerabilities in the social determinants of health. To mitigate the disparity, an array of solutions to address these inequities are discussed, thereby providing a pathway forward to eliminating this treatment gap.

BACKGROUND:Psychosocial factors have rarely been studied to understand racial differences in opioid use disorders (OUD). We investigate religious involvement and Black-White differences in OUD risk between 2004-05 and 2012-13. METHODS:We use Non-Hispanic Black and White adults from the National Epidemiologic Survey on Alcohol and Related Conditions (wave 2, N = 26,661 and NESARC-III, N = 26,960) (NESARC). We conducted survey-weighted logistic regression to examine whether race moderates the association between religious involvement and lifetime DSM-IV and -5 OUD and whether those differences change (i.e., are modified) by time, adjusted for covariates such as age, education, and urbanicity. Religious involvement measures were service attendance, social interaction, and subjective religiosity/spirituality. RESULTS:The prevalence of lifetime DSM-IV (3.82 vs 1.66) and DSM-5 (2.49 vs 1.32) OUD in NESARC-III was higher among White compared to Black respondents. Never attending services declined for both races over time. Race moderated the association between service attendance (F(4,65) = 14.9, p = 0.000), social interaction (F(4,65) = 34.4, p = 0.000) and subjective religiosity/spirituality (F(2,65) = 7.03, p = 0.000) on DSM-IV OUD in wave 2 and using DSM-5 OUD in NESARC-III (F(1,113) = 2.79, p = 0.066). Race differences in religion and DSM-IV OUD risk was modified by time (i.e., survey year) (all p < 0.000). For instance, higher service attendance was associated with lower DSM-IV risk for Black respondents in wave 2 but higher risk in NESARC-III. There were no changes in regression slopes among White respondents. CONCLUSIONS:Religious involvement may be important for prevention and treatment practices that respond to racial differences in risk of OUD. Replicate studies should examine other religious factors and specific types of opioids.

BACKGROUND:Most published treatment trials for cocaine use disorders (CUD) have been conducted with samples composed predominantly of White men and underrepresent women and racial/ethnic minorities. Because of the high prevalence of men and White individuals in CUD treatment trials, results from studies that have compared treatment outcomes by gender and race or ethnicity separately may not be representative of women or racial/ethnic minorities. METHODS:With a sample pooled from seven randomized clinical trials of treatment for CUD (n = 629), baseline characteristics and treatment outcome responses were compared with 4 subgroups of individuals created based on the intersection of gender and race (White men, Black men, White women and Black women). RESULTS:At baseline, sociodemographic status, pattern, frequency and severity of cocaine use, psychiatric comorbidities, employment and legal problems significantly differed across groups. Treatment outcome indicators collected during treatment and through follow-up, consistently indicated poorer outcomes among the sample of White women, but were similar for the other groups. CONCLUSIONS:Men and women with CUD from both racial groups enter treatment with different psychosocial issues (e.g., history of violence/trauma, financial problems, co-occurring psychiatric disorders) and substance use problems (e.g. types of substances) that may impact treatment outcomes and indicate a need for culturally-informed care to deliver more effective treatment for CUD. Poorer overall outcomes among White women may reflect the need for a more focused treatment approach for this group; and highlight the importance of evaluating gender and race in treatment trials to better address health disparities.

While much of the social and political attention surrounding the nationwide opioid epidemic has focused on the dramatic increase in overdose deaths among white, middle-class, suburban and rural users, the impact of the epidemic in Black communities has largely been unrecognized. Though rates of opioid use at the national scale are higher for whites than they are for Blacks, rates of increase in opioid deaths have been rising more steeply among Blacks (43%) than whites (22%) over the last five years. Moreover, the rate of opioid overdose deaths among Blacks already exceeds that of whites in several states. The lack of discussion of Black overdose deaths in the national opioid discourse further marginalizes Black people, and is highly consistent with a history of framing the addictions of people of color as deserving of criminal punishment, rather than worthy of medical treatment. This article argues that, because racial inequalities are embedded in American popular and political cultures as well as in medicine, the federal and state governments should develop more culturally targeted programs to benefit Black communities in the opioid crisis. Such programs include the use of faith-based organizations to deliver substance use prevention and treatment services, the inclusion of racial impact assessments in the implementation of drug policy proposals, and the formal consideration of Black people's interaction with the criminal justice system in designing treatment options.