For years, we have studied and cared for patients living with a condition that resulted in annual death rates in the U.S. of more than 100,000 people per year. Now, we have seen the first real sign of hope in more than a decade: a stunning 14% decline in the national overdose death rate.
We are encouraged by this sharp decline, yet are also deeply troubled that this hard-fought progress is not being shared equally across all our communities. While overdose death rates for white people had fallen dramatically by 2022, that isn’t the case for Black people. In 2022, their overdose death rates rose to 1.4 times higher than those for White people. Death rates for Native Americans continue to be highest of all. Black people also face disparities in alcohol-related health outcomes and more severe social consequences related to substance use compared with white people, despite similar rates of use. These disparities have been attributed to structural determinants including inadequate access to harm reduction services, as well as a treatment system that is not designed to meet the needs of all communities.
But change is possible. At Boston Medical Center’s Grayken Center for Addiction, we have worked with colleagues on new research that outlines specific steps that treatment programs can take to make addiction treatment more effective and equitable for Black patients.
The racial disparities we see in substance use outcomes are in many ways a consequence of biased clinical practices and inequitable provision of services that have fueled distrust of the medical system. Medical mistreatment of African-American patients throughout our nation’s history is well known. Beyond that, Black communities have less access to lifesaving medications for opioid use disorder and often face ongoing racial stigma from inside and outside health care.
We looked for ways to close these critical gaps in treatment between white and Black patients by going directly to the communities we serve and listening to patients and families with lived experience. Approximately 70% of our hospital’s patients are people of color, and we wanted to hear what was working, and what wasn’t.
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We held several day-long meetings, gathering an interdisciplinary group of experts, which included members of the community, treatment providers, people who have themselves experienced addiction, policy makers, and researchers, most of whom are Black, to develop actionable steps, which we recently shared in Social Science & Medicine:
- Proactively hire team members with lived or deeply understood cultural and clinical experience. Personal experience of substance use can increase staff members’ empathy and compassion toward patients, and can make them more trustworthy for patients. For example, a staff member may relate better to a patient’s hesitance to attend a Narcotics Anonymous group meeting if the patient is taking medication for opioid use disorder, since patients are often judged for medication use in this setting. Another example would be a Black staff person with prior experience as a patient in treatment programs being able to provide peer support to a Black patient who believes they have been treated unfairly in the program because of their race.
- Continue to educate all treatment staff on this history of bias and ways to deliver culturally inclusive care. While we know that people are generally more comfortable receiving care from providers who understand cultural nuances in their lives, addiction treatment programs often lack staff diversity. Educating all staff on culturally inclusive care will result in better outcomes in treatment and fewer overdose deaths.
- Build capacity to acknowledge and address trauma in addiction treatment programs. Screening for trauma, including racial trauma, is essential to meet the needs of patients in addiction treatment settings. Traumatic experiences are highly prevalent among patients who are living with substance use disorder, and Black patients in our study reported high level of racial trauma as well. People who develop addiction frequently have a history of early-childhood trauma, and symptoms of post-traumatic stress disorder can flare once use of substances stops. This leaves patients without a familiar method to cope with symptoms of trauma, and often leads to relapse.
- Avoid punitive approaches to treatment and adopt strength-based approaches. Tragically, Black people in the U.S. are much more likely to experience incarceration related to substance use than are white people, in spite of roughly similar rates of substance use. Additionally, residential addiction treatment programs too often operate in a punitive way that may trigger traumatic memories. Failure to abide by program rules is often met with threats and sanctions. For instance, some programs restrict cellphone use or visits with loved ones in response to patients not adhering to the program schedule or community guidelines. Similarly, some programs do not allow patients to go outdoors except for brief breaks under staff supervision. Evidence of relapse often results in automatic expulsion, despite the fact that addiction is known to be a chronic relapsing disease and return to use is an indication for increased intensity of treatment and support, not termination of treatment. Fortunately, there are evidence-based treatment approaches that rely on strengths and rewards, such as the Community Reinforcement Approach, and Contingency Management. Moving to these approaches can be beneficial for all patients.
The decline in the national overdose death rate presents an opportunity to finally change the narrative for all people experiencing addiction — including Black communities that are being left behind. First, we must listen to the communities we serve, and then act with intentionality. We can create a model for equity and antiracism in addiction treatment that can inform all areas of medicine, so all patients and communities can thrive.
Natrina L. Johnson, Ph.D., is a research scientist at the Grayken Center for Addiction, Boston Medical Center. Miriam Komaromy, M.D., is a professor of medicine at the Chobanian and Avedisian School of Medicine at Boston University and senior medical director at the Grayken Center for Addiction, Boston Medical Center.
