Effective Treatment of Opioid Use Disorder among African Americans

The current opioid epidemic substantially affects African Americans given their historical rate of disparities in access to effective substance use disorder (SUD) treatment. Yet, there is limited information about factors that may improve access to effective opioid use disorder (OUD) treatment for members of this racial group. This chapter describes policy, management, and treatment practices that may enhance access and engagement of African Americans in OUD treatment considering the current opioid epidemic and the state of public treatment systems in the United States. Drawing from a sociocultural framework on disparities in access to care, I present a comprehensive approach based on culturally competent and medication-assisted treatment that may reduce the wait time to enter treatment and increase treatment engagement and recovery rates among African Americans seeking OUD treatment. I focus on the role of public insurance (i.e., Medicaid), the diversification of the workforce, as well as delivery of adequate dosages of maintenance opioid medications (methadone, buprenorphine, and naltrexone) to improve engagement and recovery. Implications for health policy, program design, and service delivery are discussed to abate the effect of the opioid epidemic on African American communities.


Introduction
African American communities are disproportionally affected by the opioid epidemic. The CDC estimates that from 2014 to 2016 opioid overdose deaths increased by 45.8% for whites but 83.9% for African Americans [1]. Although white and rural communities have reported alarming overdose rates, African American communities in urban and suburban communities have seen a steady growth of overdoses over a longer period. In particular, the opioid epidemic has disproportionately affected African-American communities, who are most likely than whites to be uninsured or underinsured and unable to enter and stay in opioid use disorder (OUD) treatment.
It is well established that African Americans are more likely than whites to experience difficulty entering and staying in outpatient SUD treatment [2-6]. Researchers have examined wait time to enter treatment and retention in treatment to develop strategies to improve treatment engagement and improve the likelihood

Cultural competence to enhance access and engagement in OUD treatment for African Americans
Cultural competency is theoretically justified, and mounting evidence supports some of the multiple components or practices to improve engagement and OUD treatment outcomes [18]. However, standardized and empirically validated comprehensive scales through which to measure organizational cultural competence have been lacking [19]. Yet, workforce diversity, which allows matching clients and providers based on language and cultural background and ensuring connections with minority communities have received empirical support [7,20]. These measures of workforce diversity based on matching have been associated with higher treatment access and retention. A meta-analysis also showed a small, but significant treatment effect of culturally adapted interventions on substance use behaviors among African Americans and Hispanics [21]. This previous research shows promise but requires policy and program investment in tailoring services to the needs of African Americans.
Workforce diversity has become an effective practice to address healthcare disparities in treatment outcomes [22][23][24]. Following Brach and Fraser, I define workforce diversity as the demographic and cultural representation of health workers and managers that reflect inclusion of backgrounds that are representative of the client population [25]. A diverse workforce is one of the main practices of cultural competence, which is defined as a set of behaviors, attitudes, and policies that enable a system, organization, or individual to function effectively with culturally diverse clients and communities [18]. I draw from the culturally and linguistically appropriate services (CLAS) denomination used by federal health agencies [26][27][28] describes a healthcare system responsive to the cultural and linguistic service needs of members of racial and ethnic minority individuals.
Workforce diversity as a key practice in CLAS may help OTPs engage African-Americans who are most likely to drop out of treatment. Previous cross-sectional analyses of national representative databases show that SUD treatment programs that cater to minority populations experience decreased retention in treatment or employed methods to maintain retention [9-11, 29, 30]. In contrast, SUD treatment programs with African American supervisors [16] predicted highest degrees of cultural competence. As culturally competent practices can encompass a wide array of organizational arrangements, practices, and services, it is critical for program administrators and counselors to determine which components of CLAS are needed to engage African Americans in OUD treatment.
The importance of diversifying the workforce and delivering CLAS in the SUD treatment system stems from disparate research suggesting that the discordance between the racial background of clients and treatment staff may contribute to health and healthcare disparities [16,[31][32][33][34]. Congruence between the cultural and the linguistic backgrounds of staff and clients is thought to elevate the competencies of healthcare providers and improve client treatment adherence via the use of racial/ethnic history and cultural norms, as well as the reliance on client's native language [16,[35][36][37]. Furthermore, having a diverse workforce may create a conducive climate for implementing CLAS [38,39] and addressing treatment outcome disparities among minorities [16,[40][41][42]. The field has seen an increased diversity among SUD clients, but it is not clear how reliably provider/client matching yields positive results [16,17,[43][44][45].
Federal, state, and professional organizations have promoted cultural competence to improve SUD treatment engagement (see DHHS Office of Minority Health). Federal regulation, through Medicaid payments of healthcare service has strengthen the focus on delivering services that respond to the cultural and linguistic services needs of clients (DHHS, Medicaid). The National Institute of Medicine, National Institute of Nursing, and the National Association of Social Workers have promoted workforce diversity strategies, as well as developed training standards for cultural competency [46][47][48][49][50]. Regulation at the federal, state, and professional certification levels has incorporated cultural competence in healthcare services [51][52][53][54]. More directly to the proposed research, the Substance Abuse and Mental Health Services Administration called providers to rely on CLAS because the majority of SUD counselors are non-Hispanic whites even as almost half who seek treatment are non-white.
Prior research shows that the minority background of managers and counselors is associated with higher rates of treatment access and retention among Latino and African American clients [55][56][57]. The use of the proposed conceptual framework may expand understanding of drivers of workforce diversity and treatment outcomes.
To improve the quality of care provided to African American communities, it is critical to ensure that the different stakeholders understand the service needs of African Americans. This includes engaging policy makers, healthcare administrators, program directors, as well as treatment providers, clients, and people living in the service area who are not clients of the healthcare organization. This comprehensive approach to improve the cultural competency of OUD treatment can have a significant impact on access, retention, and recovery rates of African Americans struggling with OUDs.

Medication-assisted treatment and ensuring adequate dosages of opioid maintenance medication
Medication-assisted treatment (MAT) is a pharmacological intervention that relies on specific drugs (e.g., methadone, buprenorphine, or naloxone) to reduce Effective Prevention and Treatment of Substance Use Disorders for Racial and Ethnic Minorities the cravings or block the effects of opioid use. Unfortunately, only one-third of SUD treatment programs offer MAT in the United States, while those opioid treatment programs (OTPs) who provide these medications may not deliver them in adequate dosages compromising the recovery of clients.
Methadone is the most common opioid maintenance medication in the United States. It is used as a replacement for illicit opioid use, such as heroin, in medically supported opioid substitution maintenance programs, referred here as OTPs [58]. Buprenorphine, introduced after methadone, has received significant support to reduce illicit opioid use but has not been widely implemented in OTPs. The effects of buprenorphine may last longer than methadone as it can be taken once every 2 days.
The issue of OTPs providing adequate dosage has been an increasing concern considering the high regulation of medication-assisted programs and the impact on the client population. Emerging research suggests that Methadone doses higher than 60 mg/day are associated with significant declines in heroin consumption [58] and other drug use, as well as with longer retention in treatment and lower rates of relapse [59][60][61][62][63].
However, 41% of patients received lower doses [64] with African Americans more likely to receive doses less than 40 mg/day [17]. This initial findings are concerning as African American communities are disproportionally affected by the opioid epidemic and face significant barriers to access OUD treatment.
Significant evidence shows that buprenorphine at high doses (15 mg) can reduce illicit opioid use effectively [65]. There is limited evidence of African Americans receiving inadequate dosages of buprenorphine, but research has showed that African American communities have less access to buprenorphine treatment compared with White communities.
Adequate dosage of naltrexone is suggested at 50 mg/day [65,66], but similar to buprenorphine, evidence is limited regarding the adequate dosage of naltrexone in African American communities, while there is some evidence that these communities have less access to naltrexone compared to white communities. Enhancing African American communities' access to MAT and ensuring that maintenance dosages are adequate to maintain recovery should be a primary goal of public health leaders to abate the opioid epidemic.

Conceptual framework
The sociocultural framework of substance abuse service disparities [67] suggests that racial disparities in treatment service use originates when healthcare system factors, such as policy, community, and providers differently respond to individuals partly based on their racial/ethnic background. For instance, different stratified conditions emerge when healthcare markets fail in minority communities creating different pathways to access treatment. At the provider level, poor patient-provider communication, lack of trust, and poor workforce availability or competency further differentiates services to minority from services to white clients. As a result of these differences in service provision, racial minorities face greater risk than non-Hispanic whites of dropping out of care and receiving lower quality of care, resulting in worse treatment outcomes [68]. Growing evidence in differences in implementation of health policy in minority communities, provider discrimination, and provider resources offer support for this framework.
I also draw from a diversity and inclusion and funding and regulatory frameworks to describe how racial disparities in OTP may emerge and how to eliminate them. The diversity and inclusion framework proposes that by increasing racial diversity of the OTP workforce, OTPs will be able to be respond to the barriers to access and engagement in treatment [69]. Developing a diverse workforce may enhance OTPs' capacity to deliver CLAS, but OTP's organizational and client factors may determine when OTPs workforce diversity and delivery of culturally responsive care have an impact on process outcomes.
Opioid treatment programs (OTPs) rely heavily on their regulatory and funding environment for financial and nonfinancial (i.e., professional expertise) resources, making them vulnerable to funding and regulatory expectations [7,70]. OTPs also rely on having a high staff to client ratio to respond to client service needs. The racial/ethnic diversity of the client population is also critical for OTPs to invest in cultural competency and improving process outcomes [16]. These dynamics are consistent with resource-dependence theory [71], which posits that high dependence on necessary resources (Medicaid funding, staffing, and diverse base) determines an organization's practices (e.g., workforce diversity) and selection of core service technologies (e.g., CLAS).
By accepting Medicaid funding, OTPs increase their revenue, but also are pressured to comply with government-endorsed culturally responsive care [72,73]. Because accepting Medicaid payments may be a proxy for institutional pressures to deliver CLAS and enhance access to healthcare, Medicaid acceptance and the delivery of CLAS may potentially reduce disparities in process outcomes among OTPs primarily serving African Americans and Hispanics. Delivering CLAS may improve OUD treatment programs access, increase retention, and increase percent of clients receiving adequate MAT maintenance dosage when OTPS accept Medicaid payments and when staff/client ratios are high.
Providing African Americans with adequate dosages of methadone, buprenorphine, and or naltrexone is likely to support their commitment to maintenance medication and improve their recovery efforts. A consistent and adequate dosage of these maintenance medications is associated with positive psychosocial, emotional, and labor outcomes. Hence, it is critical to develop the health policies, insurance coverage, service practices, and workforce competencies to deliver culturally responsive and adequate dosing of opioid maintenance medication.

Organizational factors improving cultural competence and recovery
Prior research on cultural competence in SUD treatment using national data has found that SUD treatment organizations with the highest degree of cultural competence have clinical supervisors and staff who are African American [16]. Studies also show that SUD treatment, when provided using different CLAS, is associated with reduced racial disparities in client access and engagement [7]. For instance, in one of the largest studies on cultural competence, Dr. Guerrero and colleagues included measures from more than 110 treatment organizations and clinical records from 28,000 clients from minority backgrounds. Using these data, they showed that culturally responsive practices are significantly related to client access to treatment services, retention in treatment, and treatment completion [74]. The comprehensive set of organizational practices, (culturally responsive policies and practices, outreach to minority communities, workforce diversity, involvement in minority communities, etc.) make a differences in enhancing treatment access and engagement, as well as ensuring clients meet their treatment plan goals to be successfully discharged.
A critical aspect of OUD treatment is medication dosage. Growing evidence suggests that OTP client characteristics and organizational factors are associated with methadone dose levels [73,75]. Characteristics of patient mix (percentage of African American patients), employment status (percentage of patients who are currently unemployed), and patient age (percentage of patients aged 40 or above) are associated with dosage levels above 60 mg/day. Program factors associated with methadone dose levels below 60 mgs/day also include program ownership (public, private for profit, and private not-for-profit) accreditation by either the Joint Commission (TJC) or the Commission on Accreditation of Rehabilitation Facilities (CARF), the percentage of staff members who are ex-addicts [75] and African American director, particularly in programs serving populations with higher percentages of African American patients [17,64,76]. It is critical to understand the extent to which CLAS may improve OTPs' likelihood of providing adequate MAT dosages in programs serving African American and Latino clients.
Altogether, organizational factors play an important role in the delivery of quality of care for African Americans. When treatment programs provide culturally responsive care, clients engage and respond to treatment. This means that if OTP services are delivered by African American staff with competencies to understand and address the cultural, linguistic, and social service needs of African American clients, these clients are likely to enter, stay, and benefit from OUD treatment.

Conclusions
African Americans seeking to enter SUD treatment face significant challenges to engage, stay, and benefit from treatment. Increasing evidence suggests that culturally responsive practices that include workforce diversity as well as policies, practices and services that are responsive to the service needs of African Americans may improve the effectiveness of SUD treatment. African American clients struggling with OUDs may benefit from MAT, in particular three of the most effective medications to address OUD, methadone, buprenorphine, and naltrexone, but ensuring that OTPs deliver MAT, adequate dosages to help African American clients achieve medication maintenance and recovery is critical.
The socio-technical and cultural framework offered in this chapter highlights several factors that may improve treatment of OUD among African Americans. The health policy like Medicaid expansion coverage will ensure effective access to treatment by ensuring ability to pay. This funding also regulates the quality of care, including provision of culturally responsive practices, which include having staff that represent the racial background of clients. The assumption is that the provideclient matching will elevate the cultural understanding of client's OUD issues and address them effectively. The provision of MAT is critical to address OUD, but ensuring adequate dosage of the right type of maintenance medication is necessary. Healthcare system administrators, program managers, and addiction counselors should ensure that African Americans have effective access to the right medication at adequate dosages, and that outcome reporting is available.

Implications for OUD treatment for African Americans
Opioid use disorder treatment for African Americans may become more effective when investing in program design, a diverse workforce, and MAT. Because research has showed that culturally competent units are typically public, federal-funded organizations and with highly trained staff, in terms of college-educated and professionally certified, it is critical to rely on public funding (Medicaid), professional accreditation standards, and build on staff competencies to deliver OUD treatment that is effective. Culturally competent programs also have a high percent of clients with high severity of illness and social issues [16]. To increase the effectiveness of OUD treatment for an African American population that struggles with other health-related issues, it is critical to integrate MAT and medical services. Because SUD treatment programs that invest in cultural competence are more likely to invest in ancillary servicessuch as employment counseling, spiritual strength, and physical health, it is also critical for Medicaid reimbursement policies, insurance coverages, program management, and services delivery to respond to the multiple service needs that compromise the recovery of African Americans from opioid use [16,17].
Policy makers, healthcare administrators, program managers, and counselors need to work conjointly to use their unique knowledge to tailor policies, adjust budgets, design healthcare coverage, and services and prepare the workforce to response to the services needs of African Americans. To reduce the impact of the opioid epidemic on African American communities, public health systems need to improve access to culturally responsive and evidence-based care including effective MAT. Tailoring policies and services to the needs of the racial minority group most represented in OUD treatment has benefit to all members of society.

Acknowledgements
I would like to acknowledge Dr. Thomas D'Aunno for all of his mentorship, assistance, expertise, and collegiality over the many, many years. His support and guidance when I was a student are the primary reasons behind my interest in the topic of African Americans and substance use disorders. I am eternally grateful for the impact that he has had on my professional life.

Conflict of interest
The author declares no conflict of interest.

Thanks
I would like to especially thank Dr. Erick Guerrero for the invitation and opportunity to contribute to this important book.