4 Ozetta Harris: A Story of Sobriety 6 Len Collins:
18 CarolineGreene: AWalk To Sobriety 34 EdwardMcGhee: Cultivating Legacies 38 Jim Joyner: Addressing the Factors 40 Yvonka Hall: Solutions to Disparities 42 Benny Richardson: Life Decisions
14 Karell MCDaniel: Spirituality in Recovery 16 A Deadly Dose: Fentanyl Overdoses in the African American Community A Profile on the Executive Director 11 TheOpioid Crisis: An Urgent Issue
A Story of Sobriety Telling the Story Sharing the Success:
Since the start of the pandemic, medical professionals have turned to telehealth and other virtual resources to assist their patients and clients. As a recovery support advocate Ozetta Harris has become familiar with video conferencing programs. She co-hosts three daily group recovery sessions.The latest session is called “Chop It Up” and is a platform that facilitates discussions on situations threatening attendees’ sobriety.The conversations are designed to cover all types of addiction, as Harris believes anyone recovering needs to know their concerns and needs are heard. “When these people enter recovery, what they were dependent on got pulled from under their feet, so it could be easy for them to return to what made them comfortable,” she said. “I’m speaking from experience.” Her journey with substance abuse started with a seed of exclusion and loneliness during her childhood. Harris lived with her mother, whose house was often the active nightspot of the neighborhood. Other parents taught their children to avoid the house and everyone who lived there. After dealing with ridicule all throughout her school-aged years, Harris received a job at a local bank. But aiding in credit card fraud with other employees left her jobless and with a one-year prison sentence. “I felt like I was messed up and felt I had really let everyone down.That’s when I started drinking.”
Recipe to Life
She began the decline on the road of alcoholism, unable to continue any attempt at sobriety for more than a couple of years. Her husband at the time often enabled her addiction. She was repeatedly arrested from her home after becoming aggressive while inebriated. In one instance prior to receiving a sentence, Harris stood before a judge who captured the severity of her addiction. “The judge held up a stack of papers that listed how many times I’d been arrested for
-Ozetta Harris “I want them to see they always have a way out.”
In 2015, Harris received her counseling license. “In 2018, I went to UMADAOP again, not from a mandate or requirement for community service, but as a productive citizen.They asked me to come back because I have a story and something I can offer others going through what I did.” Harris often returns to the neighborhoods and shelters she frequented during her years of addiction to share her story and hopes to inspire those currently dealing with addiction. “I always want to do this for people like me,” she said. “This is the reason I do what I do.” As she continues counseling, Harris is also producing a Youtube series called “The O-Zone.”The show will host people who are well into their years of sobriety and give them a platform to talk about their successes and experiences with recovery programs. “When I’m helping people, it helps me. I want them to see they always have a way out. I want those sharing in this experience to also realize that and pass it to anyone watching.” Harris’s vision for the show began in April 2020. Her journey through addiction and story of triumphs will be featured as one of the episodes. disorderly conduct,” Harris said. “I stood before that judge a broken woman, like a car wreck. She told me I wasn’t only dealing with alcohol abuse, but also a mental disorder. She told me that when I got out, I’d go to treatment. And that’s what did it for me.” After serving her time in jail, Harris spent a couple of months in treatment and was then assigned a sponsor to assist her through the later stages of recovery. Her community service requirement gave her the opportunity to work at Cleveland UMADAOP cleaning the facility. She soon received close mentorship from one of the program’s employees who later relieved Harris of her cleaning duties. She told Harris to, instead, spend the remainder of her service hours watching recordings of the organization’s group sessions. “I got used to coming in, watching those tapes, and hearing different people’s stories. But my life changed one day when I sat down to watch the next tape and I heard someone telling my story. I saw a woman who seemed hopeless like me speaking on how she overcame her struggle. It’s like she gave me the recipe to change my life.”This marked the start of Harris’s journey to recovery. She now vividly recalls having her last experience with alcohol in 2006 and has continued her walk of sobriety since. The O-Zone
Exceeding the Standards of Treatment
Since 2001, Len “LC” Collins has been the executive director of the Cleveland Treatment Center (CTC). He began his work in the medical field as a medical illustrator with the Cleveland Department of Public Health. His work alongside department leaders and attendance at community meetings gave him ideas of ways to better connect with parts of the community struggling with drug addiction, mental health, violence, gangs, and HIV. Collins began working to create messaging that was culturally relevant, specific, and sensitive to the various target groups. “I was later asked to be a health educator, and I started looking for opportunities to give drug counseling and treatment less of a negative connotation among the public.”
We have to be culturally competent. We have to produce inclusive programs, not just for minorities, but of others also so all people have access to quality health and life experiences. Collins says changing perspectives and methods around education related to drug misuse and the negative misconceptions about MAT is a significant way to address the opioid epidemic and promote prevention. A program designed to discuss prevention methods may unintentionally create curiosity in its audience. “Some programs will talk about the different types of opioids and where they’re commonly distributed. Clients may also learn about what it takes to get high on those drugs and what those highs can feel like. After receiving that information, someone may go out seeking those dealers or sources of fentanyl and the high they’ve learned it can bring.” Collins says the CTC works to educate their clients not only on the realities and detrimental effects of addiction but also on the possibilities that arise from change and recovery. “Programs shouldn’t just be focused on teaching people how not to get high, but they should also be teaching them how to live.” been a marked increase in deaths in the African American population due to fentanyl being added to cocaine.
Changing Perspectives
Now as the CTC’s executive director, Collins is responsible for managing the organization’s daily operations. The center is the first fully accredited service provider in Northeast Ohio by the Commission on Accreditation on Rehabilitation of Facilities as an opioid treatment program. Through its medication-assisted treatment (MAT), the program serves more than 500 individuals. Since just before the start of the coronavirus pandemic, Collins says there has been a significant uptick in overdose cases in Cleveland and surrounding areas. “There have been more people who have died in the last two years than in the previous 18. He says the common link is fentanyl, as increasing amounts of drugs are laced with the synthetic opioid. According to the Cuyahoga County Medical Examiner’s Office, there has
- LC Collins
Youth Programs Collins’s position allows him to provide
creative youth programs provide productive activities and outlets for children and teens whose caregivers are struggling with addiction. The center also stands as the 41st Berkeley College of Music community networking site to offer music history and education to young individuals. Let it Ride, one of the program’s youth bands, released an album titled Got it Going On and has performed at corporate and other social events to spread the message of recovery in nontraditional ways. Outdoor, technical, and job training also give the young attendees practical skills to position them for productive and successful futures. “Our kids can get their boating license, learn archery, and become camp leaders across the county,” Collins said. “When they first start with us, we ask them what skills they don’t have. Then we know what more to incorporate into our programs.” As the organization continues to grow, Collins says the focus will remain on excelling as a community resource for cost-effective
representation for the program’s consumers. His responsibility for writing grants and applying for funding means he can bring the needs and concerns of the clients he sees daily and include them in decisions. “What we do comes from a humanistic approach to care.”
While the center focuses on drug treatment, its reach spans further and is known to the community as an arts-related program. In the last four years, the center has produced two New York Times bestselling graphic novels. Its
and abstinence-based drug prevention and treatment.
THE OPIOID CRISIS AND THE BLACK/AFRICAN AMERICAN POPULATION : AN URGENT ISSUE
Drugs.” This resulted in widespread incarceration of drug users and disruption of primarily Black/African American families and communities. This population was criminalized for drug-related offenses at much higher rates than White Americans and this has had lasting effects through the present day. 7 In 2017, though Black/African Americans represented 12 percent of the U.S. adult population they made up a third of the sentenced prison population. 8 In 2012, they accounted for 38 percent of the sentenced prison population in the U.S. and 39 percent of the population incarcerated for drug-related offenses. 9 * In this issue brief, Black/African American is used as an umbrella term to include those who identify as “African American” and/or “Black” in the U.S. When data are reported, if describing specifically the non-Hispanic Black population, “non-Hispanic Black” is used. Today, the response to the drug epidemic is framed as an urgent public health issue. Substance use disorders (SUDs) and addiction are now viewed as a health condition, a disease that needs to be prevented and treated, and where recovery is possible with appropriate services and supports.
Introduction T he current opioid epidemic is one of the largest drug epidemics recorded in U.S. history for all racial and ethnic groups. From 1999 to 2017, there were nearly 400,000 overdose deaths involving opioids in the U.S. 1 In 2018, 10.3 million people misused opioids, including prescription opioids and heroin, and two million had an opioid use disorder (OUD). 2 In 2017, the opioid epidemic in the U.S. was declared a national public health emergency with 47,600 reported deaths from opioid-related overdoses, which accounted for the majority of overdose drug deaths. 3 With approximately 130 people dying each day due to an opioid-related overdose, 4 this epidemic has garnered nation-wide attention, generated significant federal and state funding for prevention, treatment, and recovery and shaped the priorities of many local communities. Attention to this epidemic has focused primarily on White suburban and rural communities. Less attention has focused on Black/African American* communities which are similarly experiencing dramatic increases in opioid misuse and overdose deaths. The rate of increase of Black/African American drug overdose deaths between 2015-2016 was 40 percent compared to the overall population increase at 21 percent. This exceeded all other racial and ethnic population groups in the U.S. 5 From 2011-2016, compared to all other populations, Black/African Americans had the highest increase in overdose death rate for opioid deaths involving synthetic opioids like fentanyl and fentanyl analogs. 6 Three decades ago, when opioids and crack cocaine were devastating Black/African American communities, the national response was “The War on
PURPOSE OF THE ISSUE BRIEF
As Congress, federal agencies, state health departments, and other stakeholders mobilize to address the opioid epidemic, what is happening within the Black/African American communities? This issue brief aims to convey snapshots of how this population is impacted. Specifically, it aims to do the following: a) Provide recent data on prevalence of opioid misuse and opioid overdose death rates in the Black/African American population in the U.S.; b) Discuss contextual factors that impact the opioid epidemic in these communities, including challenges to accessing early intervention and treatment; c) Highlight innovative outreach and engagement
strategies that have the potential to connect individuals with evidence-based prevention, treatment, and recovery and;
THE OPIOID CRISIS AND THE BLACK/AFRICAN AMERICAN POPULATION: AN URGENT ISSUE
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d) Emphasize the importance of ongoing community voice and leadership in the development and implementation of solutions to this public health crisis.
WHAT DO THE NATIONAL DATA SHOW?
National and state opioid estimates are from the Substance Abuse and Mental Health Services Administration (SAMHSA) National Survey on Drug Use and Health, 10 and the Centers for Disease Control and Prevention (CDC) National Vital Statistics System. 11 In the figures and tables below, the most recent available data are shown. Opioidmisuse. The opioid misuse rate among non- Hispanic Blacks is similar to the national population rate, about 4 percent. 2 In 2018, 1.2 million non- Hispanic Blacks and 10.3 million people nationally, aged 12 and older, were estimated to have had opioid misuse in the past year. 2 Opioid-related overdose deaths and deaths involving selected drugs by race/ethnicity. The opioid-related overdose death rate for the national population increased from 2.9 deaths per 100,000 people in 1999 12 to 14.9 per 100,000 in 2017 3 —with a large increase in overdose deaths involving synthetic opioids other than methadone (synthetic opioids, i.e., fentanyl, fentanyl analogs, and tramadol) from 2013 to 2017. 3 In 2017, among non-Hispanic Blacks the opioid-related overdose death rate was 12.9 deaths per 100,000 people (Table 1). It was the third highest opioid-related overdose death rate compared to other race/ ethnicities. 13 Synthetic opioids (other thanmethadone). Data suggest that illicitly manufactured synthetic opioids are heavily contributing to current drug overdose deaths in the U.S. 3,14 The fast rise in overdose deaths involving synthetic opioids in recent years is alarming and data show that the mixing of synthetic opioids with other drugs occur across populations. 15 Synthetic opioids are affecting opioid death rates among non-Hispanic Blacks more severely than other populations. 3,12-13 In 2017, non-Hispanic Blacks had the highest percentages of opioid-related overdose deaths and total drug deaths attributed to synthetic opioids when compared to other race/ethnicities and the national population (Table 1). 13 Synthetic opioids accounted for nearly 70 percent of the opioid-related
SOURCES OF INFORMATION
This issue brief includes information compiled from a variety of sources, including interviews with key informants, federal data, and the peer-reviewed research and policy literature. Key informants were selected for their expertise and current work to reduce opioid misuse and provide treatment and other services in Black/African American communities. They represented a range of roles—including community leader, person with lived experience, peer recovery coach, peer recovery supervisor, executive director and staff of community-based programs, evaluator, researcher, addiction psychiatrist, clinical psychologist, physician, social worker, nurse, and city representative. The information they shared represents a snapshot of what is happening in selected Black/African American communities struggling with opioid misuse and is not a full comprehensive picture of this population across the country. Their direct statements, indicated by italics and quotation marks, are interspersed throughout the document.
Opioids In Black/African American Communities: C ontext
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SPIRITUALITY IN RECOVERY
addiction: biological, psychological, social, and spiritual. He
“I often wondered where religion fell into the process of treatment and recovery,” As the founder and executive director of a ministry dedicated to professionally training counselors, McDaniel often references four major theories of Throughout his nearly 40 years of work in chemical dependency counseling, Karell T. McDaniel’s sessions have spanned beyond discussions of substances and mental health. They reach deeper into an area he believes is often overlooked yet is vital to progressing through the 12 steps of recovery. His work in the field initially began as a drug counselor in the military. But after his separation in 1993, his ministerial passion and commitment to bettering treatment processes led him to pursue an uncommon path in counseling. “I often wondered where religion fell into the process of treatment and recovery,” he said. “In a lot of the treatment programs I’d seen, I noticed the religious portion was absent. That shifted my approach.” In the African-American community, where religion is the backbone of many households, McDaniel says the need for spirituality in counseling during recovery is great. “Many of these individuals have been brought up in their faith, and there is an innate desire to turn back to that faith. But as a result of their addiction, they may find their spiritual connection has been blocked or eroded.”
believes his calling in the field is to direct increased attention to the spiritual part of the recovery process. In 2006, he founded Life Recovery Ministries, an organization that provides faith-based counseling through support groups and education. He was also instrumental in founding the Recovery Church. The two organizations are designed to build a bridge between professional providers and the faith-based community. “Just as hospitals have chaplains in them, I didn’t understand why the treatment community did not have chaplains in them.” McDaniel believes the disconnect between treatment programs and spirituality prevents clients from accessing and healing parts of themselves that are vital to their recovery. In 2012, McDaniel became the chair of a faith-based sub-committee funded by the ADAMHS Board of Cuyahoga County, which led to him becoming one of the first funded faith-based providers in the county. During assessments, McDaniel and his team asked clients if they believe in God or a higher power. “About 94 percent of them always acknowledged that they did. So that became the question of their faith and how practicing their religious beliefs can be incorporated into a system to best lead them through the recovery process.”
- KARELL MCDANIEL
Restoring Faith
“I believe that our core and our connection to God or a higher power is essential however we choose to believe. ”
Because many programs are not equipped to provide spiritual guidance, clients acknowledging religious backgrounds often do not receive attention specifically geared toward restoring their faith. “I believe that our core and our connection to God or a higher power is essential however we choose to believe. Individuals who have the longest-term recovery are connected with a spiritual component of recovery. We must have our inner values, our belief systems, and our faith checked, just as we routinely do tune-ups on our cars. If I continue in addictive behaviors, that’s
- KARELL MCDANIEL
counter to what I say I believe in and a conflict that needs to be addressed during these counseling sessions.” To address this challenge, McDaniel moves his clients through eight stages of Developing a Heart for Change. The program helps its clients recenter their faith from using alcohol and drugs to cope to a revived hope in God. “It’s challenging, but it’s ultimately in line with the other treatment models. There’s a focus on the physical and mental aspects of recovery. There should be just as much on the spiritual.”
A Deadly Dose: Fentanyl IN THE African American Overdoses
Community
From 2020 reports, there were about 430 overdose deaths from fentanyl in Cuyahoga County, according to Medical Examiner Thomas Gilson. Of those, 117 were African American .
D uring the 1990s, the increasing se- verity of the prescription drug cri- sis did not primarily affect African Americans. “That may have been, in large part, because of the healthcare disparity or doctors’ approach to treating pain among Black people,” Gilson said. “But it was clear African Americans did not have the same issue with the epidemic as white suburban areas.” However, during that time and through to- day, crack cocaine has been the consistent drug of choice for users within the Black community. “It wasn’t until cocaine and fentanyl were wedded that we started see- ing the explosion of overdose deaths among African Americans from these drugs.”
was responsible for seven overdose deaths that year. In 2015, there were 25 deaths. By the end of 2017, that number had in- creased by four times. “We really started seeing fentanyl being added more in the African American community in 2016, and that was devastating.” When looking at the potency of opiates, ex- perts use morphine as the bas line for com- parison. Heroin has about four times the potency of morphine. Fentanyl, however, has 40 times the potency of heroin and 80 times the potency of morphine. Fentanyl was first introduced in the 1960s as an anesthetic or pain medication. Its use scaled as other pain medications also emerged onto the market. However, in 2015, the illicit drug market began using fentanyl and manufacturing
A potent narcotic, the use of fentanyl first spread in the Black community in 2014 and
“Fentanyl has 40 times the potency of heroin and 80 times the potency of morphine.”
it overseas. “People are always looking for anesthetics and pain killers, and fentanyl just is a very potent one.” Gilson believes drug dealers saw the opportunity to tap into a new market and introduced fentanyl to the minority community. “Cocaine is a stimulant, and fen- tanyl is a depressant. Mixing the two most seems like a business decision for people who make their living from hurting people through drugs, so fentanyl steadily in- filtrated the market.” While morphine and heroin are made from plants and require ideal growing envi- ronments, fentanyl is manufactured in laboratories, making production easier and faster. In light of the coronavirus pandemic, Gilson be- lieves there may have been some correlations be- tween 2020 overdose numbers and effects from the pandemic. “There was a spike in May, and that’s when many people received their first federal stimulus checks. That also fell around a time when many of the heavier stay-at-home restrictions were temporarily lifted. So there may have been a combination of people having extra mon- ey in their pockets and losing tolerance of being inside the house. It may have just been a perfect storm.” Gilson says risk reduction programs and efforts are the fu- ture of addressing these staggering numbers, as community leaders work to introduce greater numbers of Narcan kits to the community. They have also begun including fentanyl test strips with the distribution kits. “If someone is using drugs, knowing if it’s laced with fentanyl could modify their behavior and serve as a wake-up call to save their life.” Plans are also in place to expand county educational programs
in schools. “We want to be in middle and high schools offering timely advice and discour- aging children from going down that path.”
THE 14 DAYS…
A Walk to Sobriety
Carolyn Greene is a licensed chemical dependency
counselor. She sees clients through her remedial counseling program, Greene Acres. She says she was destined to work in recovery services, as she was once attending some of the same sessions she now hosts.
Becoming Stable
Christian mothers. Their discipline taught me how to raise my newborn child. After a year there, I got into a transitional program, and that was good progress for me. I had an apartment, kept up with my medical appointments, and attended my counseling sessions. That allowed me to save money, go back to school, get a job, and get back on my feet. When I became stable, I received visitation for my other three children. Going through family counseling with them revealed a lot of anger and trauma from my oldest kids. I didn’t know how to explain to them how I couldn’t keep them when they were younger but was able to change my life and path after giving birth to my youngest daughter. I had to learn to deal with that. My youngest daughter is 26 now, so I’m 26 years sober. I found a lot of support through AA meetings. I went to church and befriended older women I knew wouldn’t influence me to return to my previous way of life. After receiving a nudge from God to start missionary work, I left my job to be able to fully assist people going through alcohol and drug treatment. People around me saw my work and consistently encouraged me to become a social worker. I went to school to get my license. Ever since then, I’ve been working in this field. For me, I like to challenge my clients and what they believe. Whatever happened in their life challenged them, and they didn’t know how to work through that challenge. I have to figure out what that is so I can help them learn what they need to. We have to help people change for the environment they’re in, and I want to use my story to strengthen them to do that.” - CAROLYN GREENE “I don’t want to live like this anymore. I want help.”
“I started drinking at the age of 12. My parents had several after-hour joints, so alcohol was readily available. By 13, I’d started using marijuana. I participated in street life, sold drugs, and went through a lot of traumas because of it. When I was 17, I was kidnapped and later had my first child after I was raped. I was on drugs throughout that pregnancy, just like I was during my other three. When I was pregnant with my youngest child, people often said they didn’t want to sell to me and aid in the damage I was doing to my unborn baby. So I decided I was going to rob someone to get what I wanted. There was a part of me that knew I was wrong, but there was also a part of me that couldn’t correct it. I robbed them and got high for two weeks straight. One day I was sitting in the drug house, and I heard what I now know was God telling me I was going to die like that if I didn’t change something. I later agreed to go to a clinic in the neighborhood. The people there looked at me like I was crazy. I was hallucinating from being high for 14 days straight. I’d been there so many times throughout my other pregnancies and stolen so much from the clinic that the doctor refused to see me. But I just sat there. I knew this clinic was my only hope. Eventually, a social worker walks up to me and asks, ‘What do you want us to do for you?’ Something about her voice broke me down. I told her, ‘I don’t want to live like this anymore. I want help.’ That’s when they finally took me in. During my examination, they found 14 drugs in my system. The doctors told me they couldn’t help me and their only choice was to admit me to the psych ward. ‘I don’t care,’ I told them. They handcuffed me to the bed, and from that point began my journey to recovery. As I began to sober up, I was able to reflect on the decisions I’d made. I was feeling remorse for all the things I’d done. After leaving the psych ward, I was connected with a home run by older
Percent increase in overdose death rates by drug among the non-Hispanic Black population. From 2014-2017, among the non-Hispanic Black population drug overdose death rates involving all types of opioids increased, with the sharpest rise from synthetic opioids (Figure 1). 13,17 Death rates involving synthetic opioids increased by 818 percent, and was the highest for non-Hispanic Blacks compared to all other race/ethnicities (data not shown). 13,17
overdose deaths and 43 percent of the total drug overdose deaths for non-Hispanic Blacks in 2017. 13 Synthetic opioids are especially affecting the overdose death rates among older non-Hispanic Blacks. 16 From 2015-2017, non-Hispanic Blacks aged 45-54 and 55-64 had synthetic opioid-related overdose death rates double in large urban areas. 16
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t his narrative are opportunities for compassion, understanding, treatment and recovery.
Black/African Americans were 29 percent less likely to be prescribed opioids for pain. 21 Racial and ethnic minorities are more likely to experience miscommunication or misinterpretation about their pain with their medical providers. 22 For example, Black/African Americans have higher self-reported pain scores when compared to Whites, 23 yet some doctors choose to believe that pain levels are lower for Black/African Americans compared to Whites 24 or that Black/African Americans are drug seekers. This lower access to prescription opioids for Black/ African Americans contributes to at least two adverse outcomes: a myth of Black/African Americans being “perversely protected” from the opioid crisis is spread 7,25 and the potential for severe under-treatment or mistreatment of pain for Black/African Americans with severely painful medical conditions such as sickle cell disease, certain cancers, HIV/AIDS and other autoimmune diseases. 22 The data show that Black/ African Americans are not “protected” from this epidemic. And, under-prescribing in some cases may have life-threatening consequences for people affected with pain disorders. CHALLENGES TO PREVENTION, TREATMENT AND RECOVERY The social determinants of health and other community and system level factors cannot be ignored when discussing the contextual factors associated with any major public health issue. Described below are some of the key challenges associated with opioid misuse and OUD within the Black/African American population. Negative representations, stereotyping and stigma. Black/African Americans with SUDs are doubly stigmatized by their minority status and their SUD. Negative images of Black/African Americans with SUD contribute to mistreatment, discrimination and harsh punishment instead of treatment and recovery services. Even today, some Black/African American community leaders indicate that using words such as an “opioid epidemic” or “crisis” may be inflammatory in their communities, putting residents on high alert and triggering fears of incarceration. Mostly absent from
Intergenerational substance use and polysubstance use. For many families in the U.S., substance misuse is passed on from generation to generation and opioids are not the first or only drug being used. In some cases, multi-generational households are misusing opioids and other substances together. In communities with high poverty and economic disinvestment, intergenerational and polysubstance use are not uncommon nor unique to Black/African American communities. For many in these poor and low-income communities, using and/or selling drugs is a means of survival. Opioids are not the only substances of concern and are likely not being misused in isolation. An understanding that intergenerational and polysubstance use are common among some impoverished communities, and that disentangling the behaviors of a person’s social network, including their family, are challenging yet critically necessary. Fear of legal consequences. Only 10 percent of people with a SUD in the general population seek treatment. 2 This is magnified in the Black/African American community where there is significant historical mistrust of the health care, social services, and the justice system. For men, there is the looming fear that seeking treatment will result in severe sentencing and incarceration reminiscent of the harsh policies of the past. 7, 26 Stricter drug policies for possession or sale of heroin in New York known as the Rockefeller Laws were put into place in 1973, and the Anti-Drug Abuse Act of 1986 enforced across the country resulted in mandatory and severe sentencing for low-level, non- violent drug offenses, particularly related to cocaine, for a disproportionately high number of people of color compared to Whites. 7 These severe penalties have had lasting impacts on the current criminal justice system, where Black/African Americans represent a substantial percentage of drug offenders in federal prison 9 despite Whites representing the majority of illicit drug users in the U.S. 2 Black/African American women fear losing their children to the foster care system if they acknowledge a substance use problem and seek treatment. 27 These fears are a major
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are devoid of the context, [they are] not effective and it feels naïve for the folks that are living it. ” The framing of a prevention message must be tailored to resonate with the community culture and be conveyed by a trusted messenger. Unequal treatment is common in many Black/African American communities, where access to treatment options is more dependent on race, income, geography, and insurance status, rather than individual preferences, or medical or psychiatric indicators. 31-33 Research suggests that Black/African Americans with OUD have experienced limited access to the full range of medication-assisted treatment (MAT) when compared to Whites. 7,34-38 One study based in New York City found that the residential area with the highest proportion of Black/African American and Latino low-income individuals also had the highest methadone treatment rate, while buprenorphine and naloxone were most accessible in residential areas with the greatest proportion of White high-income patients. 36 Another study showed that in recent years buprenorphine treatment has increased in higher- income areas that have lower percentages of Black/ African American, Hispanic/Latino and low-income residents while methadone rates have remained stable over time and continue to cluster in urban low-income areas. 34 Among individuals with OUD, Black/African Americans in the U.S. were less likely to receive buprenorphine compared to Whites, and those who self-pay or had private insurance represented nearly 74 percent of those who received buprenorphine from 2012-2015. 38 This disparity in access to buprenorphine by race/ ethnicity, geography, income, and insurance status, may be related to barriers for both the patient and clinician. Buprenorphine is generally a less stigmatizing treatment for people with SUD compared to methadone. It is an office-based treatment available for general/primary care practitioners to prescribe and administer. Office-based treatment programs only work for patients with access to primary care, something that may be inaccessible to many low- income or uninsured people of color. While in general it may be difficult to get physicians waivered, incentives to obtain a buprenorphine waiver are often lacking for
barrier to timely treatment and support for recovery.
Misperceptions and faulty explanations about addiction and opioids. Similar to society in general, in Black/African American communities there is a lack of understanding of SUD as a disease and the high risk for OUD from prescription opioid misuse. Within all communities, and especially Black/African American communities, as one key informant stated, people are hiding their SUD because “ addiction is seen as a weakness not a disease ” and another noted that solutions must discuss “ how addiction is a disease, not a moral failing. ” Misperceptions of current treatment options also exist among Black/African Americans and their families. According to key informants, many from this population are not informed about the standard treatment options for OUD, reducing the chance that evidence-based treatments will be sought. Lack of culturally responsive and respectful care. While it can be challenging to take a holistic view of an individual and see more than the SUD, this may be even more so for the Black/African American who is subjected to the implicit biases of the health care system. Failing to bridge a racial cultural divide often contributes to premature termination of treatment among people of color. A shortage of Black/African American and Hispanic/Latino physicians, in general, and also clinicians who are waivered to prescribe buprenorphine exists. 28-30 Engaging in treatment is a difficult task for all populations. When the cultural context is ignored or misunderstood, respect for the patient is lacking, little hope is provided, and a lack of Black/African American practitioners who treat OUD exists, it becomes very difficult for a Black/African American with OUD to engage in treatment. Separate and unequal prevention and treatment. Universal, broad, substance prevention campaigns have limited impact in diverse communities, including Black/African communities. The expectation that general prevention efforts and messaging will be equally relevant to Black/African Americans is unrealistic. Messages about SUD as described by a key informant cannot be “easily uncoupled from disinvestment in our communities, mass incarceration, over-policing, over-traumatizing…when the messages
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providers serving the publicly insured or uninsured population due to limited or low reimbursement rates and lack of time and resources to pursue the training and acquire the mentorship to properly administer and care for buprenorphine patients. 34,36 In contrast, methadone must be administered in a federally regulated opioid treatment program, which has strict regulations and is often located in low-income areas. Methadone, while an effective treatment, places more burdens on the patient such as daily clinic visits, regular and random drug testing, employment disruptions, required counseling, etc. Thus, methadone —stigmatized in many Black/African American communities and as one key informant noted, “ just doing one drug for another drug ”—is often viewed as the default treatment for Black/African Americans and often the only treatment option. Essentially, a two- tiered treatment system exists where buprenorphine is accessed by Whites, high-income, and privately insured, while methadone is accessed by people of color, low-income, and publicly insured.
Effective treatments for OUD have been developed and generally work across all adult populations. 39 However, access to these treatments is uneven, 34-38 with particular obstacles for minority populations. This section begins with a description of standard treatment for OUD and overdose. This is followed by innovative outreach and engagement strategies that have been used in Black/ African American communities. These strategies, illustrated by snapshots from Black/African American communities, focus on outreach and engagement efforts that facilitate prevention, treatment and recovery. Supported by community-based participatory research efforts, these strategies are implemented by case managers, partnerships with community leaders and advocates, treatment providers, and peers/people with lived experience of a SUD.
Strategies to Address Opioid Misuse and OUD in Black/African American Communities
STANDARD TREATMENT
The evidence-based treatment for an individual with OUD is MAT administered by qualified medical personnel, while for an opioid-related overdose, it is the administration of an opioid overdose reversal drug by a trained individual. Medication-Assisted Treatment (MAT). MAT is the use of an FDA-approved medication in conjunction with a psychosocial intervention. Currently, three medications are approved for MAT: methadone, buprenorphine, and naltrexone. 40
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THE OPIOID CRISIS AND THE BLACK/AFRICAN AMERICAN POPULATION: AN URGENT ISSUE
A Rooted History:
Concerns Among CovidVaccines in the Black Community
DON’T THINK IT DOESN’T AFFECT YOU.
Millions watched as a Black intensive care nurse in Queens, New York received the first dose in the country of the Pfizer-BioNTech vaccine.
On a mid-December Monday in 2020, the Unit- ed States recorded a coronavirus death toll topping 300,000. The 10th month of lockdown restrictions brought record low numbers of holiday travel for family visits, continued effects of economic stress both on federal and inde- pendent levels and the compounding difficulty of students receiving virtual instruction. Mil- lions watched as a Black intensive care nurse in Queens, New York received the first dose in the country of the Pfizer-BioNTech vaccine. Though a leading name among vaccine production, the Pfizer vaccine has not been approved by the Food and Drug Administration. News reports also detailed side effects that occurred following some of the initial administrations of the vac- cine in various parts of the country. While these facts produced hesitation or questioning about the safety of the vaccine among many, the Black community had a greater amount of reluctance to consider. Now nearly three months into countrywide vaccine distribution, doses are going to groups of healthcare workers and employees in fields with higher risks of transmitting the virus. A report from a data tracker through the CDC stated more than 60% of these doses have gone to white people, whereas only 6% have gone to African Americans. While demographics and varying vaccination phases throughout states are factors that contribute to this disparity, historical events and patterns are perhaps the greatest factors that account for this significant differ - ence. In 1932, in partnership with the Tuskegee Insti- tute, the U.S. Public Health Service recruited hundreds of rural Black men to participate in a study they were told would treat them for “bad blood,” an all-encompassing term at the time that referenced a span of conditions and ailments. Officially named the Study of Untreat - ed Syphilis in the Negro Male, the goal was to “observe the natural history of untreated syphi- lis” among Black populations. The study’s partic- ipants, however, were not provided the scope of these intentions and were denied the education
or resources that could give them the knowl- edge needed to make informed decisions about their participation. During the study, the men were given free meals, medical exams and burial insurance. They were not aware, however, the purpose of the study was to deny them medical treatment during the process. Instead of lasting the six months it initially prom- ised, the study continued for 40 years. Penicillin was widely introduced as an antibiotic to treat syphilis in 1947, yet it was not offered to the study’s participants. They were also not given the option to halt their involvement in the study and receive treatment if desired. When a federal advisory board was called in to assess the ethics of the study, the panel found the men had been misled and the study was “ethically unjustified.” A year later, settlements and reparations were distributed. However, the hindsight perspective of the study reflects a trusted group of govern - ment medical researchers intentionally omitting vital information from a group of men either seeking treatment or volunteering to participate in a study they believed would lead to the treat- ment of syphilis. Now nearly 50 years later, as a pandemic shakes the globe, the Black community is reminded of the injustices of that experiment. A host of Black educational and medical leaders across the coun- try have voiced their support of the coronavirus vaccine and are encouraging African Americans to receive it. While some say the continued rise of vaccination numbers will assuage concerns, a justified amount of anxiety around the doses is still present for many.
1. Implement a comprehensive, holistic approach — “Addiction is beyond the neuroreceptor level.” A comprehensive, multi-layered approach is necessary to address opioid misuse and addiction. Some speculate that opioids are a way of coping in the absence of healing when a community has been traumatized by decades of violence, poverty, and neglect. As one key Five key strategies with specific community examples are described below. While not universally representative of all Black/African American communities, these strategies are examples of how some communities are addressing opioid misuse in their community. Opioid overdose reversal drugs. Currently, naloxone is the one FDA-approved medication used to reverse an opioid-related overdose. Naloxone: a prescription medication to prevent overdose of opioids such as heroin, morphine, and oxycodone by blocking opioid receptor sites to reverse the toxic effects of the overdose; it is given by intranasal spray, intramuscular (into the muscle), subcutaneous (under the skin), or intravenous injection. 46 Efforts to expand the use and availability of naloxone nationwide through federal, state, and local initiatives is a key strategy to tackling opioid overdose. The effectiveness of naloxone (Narcan) and the critical need for it during this time prompted the U.S. Surgeon General to issue a public health advisory in April 2018. 47 This advisory recommends increased availability of naloxone in communities with high rates of opioid use, including administration by a wide array of health professionals, first responders, overdose survivors, and their family members. 47-48 Similarly, in December 2018, the U.S. Department of Health and Human Services released new guidance on co- prescribing naloxone for patients at high risk for opioid overdose. 49 COMMUNITY-INFORMEDSTRATEGIES TO ADDRESS OPIOID MISUSE AND OUD IN BLACK/AFRICAN AMERICANCOMMUNITIES
Methadone: a medication that reduces withdrawal symptoms and cravings and blocks the euphoric effects of opioids like heroin, morphine, oxycodone, and hydrocodone. For treatment of OUD, it must be prescribed and dispensed from a federally regulated opioid treatment program (OTP). It is taken daily and orally, typically in liquid form but can also be offered as a pill or wafer. It may cause serious side-effects and can be addictive. 41-42 Buprenorphine: a medication that treats withdrawal symptoms and cravings and is less likely than methadone to cause intoxication or dangerous side effects such as respiratory suppression. It is commonly administered as a pill or buccal film that must be dissolved sublingually or attached to the cheek. It is also available as a monthly injection or subdermal implant that lasts for approximately 6 months. It may be prescribed and dispensed outside of a licensed OTP by physicians or qualified medical practitioners who have completed requisite training and earned a DATA-2000 waiver. 42-43 Naltrexone: a medication that blocks the euphoric and sedative effects of opioids. It is not an opioid and is neither intoxicating nor addictive. It is administered as a daily pill or monthly injection by any licensed medical practitioner or pharmacist. An extended-release injectable form, Vivitrol, is approved for treatment of opioid and alcohol use disorders and its effects last for about 28 days. 42,44 For additional information, see SAMHSA’s TIP 63: Medications for Opioid Use Disorder. 45 The second component to MAT is the psychosocial or behavioral intervention. Behavioral interventions target a broad range of problems and concerns not necessarily addressed by the medications (e.g. co- morbid mental health conditions, lack of social supports, risky behaviors, unstable housing, etc.). A few behavioral interventions such as contingency management, cognitive behavioral, and structured family therapy approaches are widely accepted as effective when used in conjunction with medications. 39 Some research has indicated that motivational interviewing may also be an effective behavioral intervention, but more research is needed. 39
THE OPIOID CRISIS AND THE BLACK/AFRICAN AMERICAN POPULATION: AN URGENT ISSUE
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For residents reluctant to engage with the medical system, these “under the radar networks” are the essential entities to enlist in the opioid response. Using indigenous leaders, and individuals in recovery to spread education about naloxone kits, may have greater impact than the usual first responders such as police officers. Working with harm reduction networks and syringe services programs are needed to reduce harms among Black/African Americans who have an injection drug use problem, and among people who inject drugs, in general. 52 As noted by one key informant, “Black community needs harm reduction because we are always under assault from drug use…[we] need prevention for STI (sexually transmitted infections). To not talk about this, [you are] not connected with Black communities.” Community Snapshot: Creating safe, comprehensive healing spaces—Bellevue Hospital. Bellevue Hospital created a holistic addiction clinic built on the creative arts, self- care, and a recovery network of support for Black/ African Americans. The clinic built in patient governance and established linkages with the community. The clinic created a home-like, welcoming environment, centered on a kitchen and cooking groups to foster a mindset of healthy eating. Patients and physicians in the clinic cooked together which was a way of establishing relationships in a non- hierarchical manner and building patient trust in a medical center. Therapeutic approaches incorporated both the structured cognitive behavioral therapy and patient groups based on the creative arts and spirituality, both highly valued within Black/African American culture. For some Black/African American groups, the cultural arts—visual, musical and drama— were an important participatory process for emotional expression, tapping into traumatic memories, and getting a sense of meaning and resilience outside of the SUD. The clinic established relationships with the surrounding community, including collaborating with Black/African American community-based organizations for housing, employment supports, food banks, churches, church-based addiction services and other trusted entities where patients could get ongoing support. The clinic assumption was that healing rests on relationships, and as described by one key informant, “[you] can’t just drop bupe into a clinic—the
informant noted, “thirty percent of the black community is under poverty in the state…these stats play into the sense of hopelessness, [people are] working full-time but not making livelihood, [there is a] sense of hopelessness that is fixed by opioids…[it’s] more than just getting people into treatment.” Another key informant stated: “So much evidence that addiction is beyond the neuroreceptor level—it’s the criminal justice system, daily life, the neighborhood—all have an impact on outcomes in addiction treatment… Medication is essential but not a magic bullet for treating opioid use disorders, [you] need more to recover successfully… not a single med that sustains recovery on its own, especially for those living in toxic environments…Rather, a comprehensive, holistic approach tailored to the community is required. For African Americans, addiction is embedded in a community context marked by limited opportunity, economic disinvestment, violence and intergenerational trauma. Research has confirmed that strong neighborhood cohesion and social ties are correlated with lower drug rates and related consequences.” Key informants emphasized the value of community- led needs assessments and routine check-ins with the community that address the social determinants of health. Having the community’s first-hand knowledge about where people live, work, learn, play, worship and age and how these places promote healthy functioning and quality of life is essential to addressing opioid misuse and OUD. Aspects of a community such as community engagement, economic stability, and neighborhood safety all have an impact on the well- being and health of its residents. These factors, often addressed by case managers, are a key component of treatment planning. Understanding the existing assets in a community is essential. Where residents go for information, whom they trust to deliver care, and who the explicit and implicit community leaders are is critical information. In some Black/African American communities, places such as barber shops, beauty salons, and the church or faith-based community are critical for delivering prevention education and linking to treatment. 50-51
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THE OPIOID CRISIS AND THE BLACK/AFRICAN AMERICAN POPULATION: AN URGENT ISSUE
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