Open access peer-reviewed chapter
Abstract
Disparities in substance use disorders (SUD) and access to treatment among individuals identified as Latino/Hispanic have become a significant public health issue in the United States. National efforts to identify, understand, and eliminate such disparities have highlighted the role of structural racism in Latino health. In this chapter, we offer a critical review of how Latino substance use and access to care may be impacted by discrimination, acculturation stress, and other mechanisms of structural racism. As structural racism is represented by policies, systems, structures, and norms that deny and/or minimize cultural strengths and disempower culturally diverse groups and their attempts to invest in their wellness, we highlight how cultural competence may reduce the risk of SUD and may enhance access to treatment among Latinos. We conclude by highlighting policies and responsive organizational practices that may improve Latino health.
Keywords
- structural racism
- cultural competence
- substance use
- Latino
- disparities
1. Introduction
According to the U.S. Census Bureau [1], 62.1 million Americans identified as Hispanic, Latino, or Latinx (hereafter Latino) in 2020, comprising approximately 19% of the total population [2]. More than half (51.1%) of the total U.S. population growth during the last decade came from growth in the Latino population [3]. Latinos, people with a historical origin in Latin American countries where Spanish language is spoken, have become the largest ethnic minority group in the United States [1]. The Latino population in the United States is diverse in national origin and acculturation status. The U.S. Latino population is largely urban and has been concentrated in large metro areas, although the population of Latinos in smaller cities and rural areas is increasing as well [4]. In 2020, the poverty rate for Latinos was 17.0 percent accounting for 10.4 million individuals [3]. Latinos constitute a young population, with 40% under the age of 20 [5]. Two-thirds of U.S. Latinos are first- or second-generation immigrants [5].
Many of the risk factors for Latino substance use are associated with rejection from their environment and associated stressors. This may be construed as bias, discrimination, and/or racism in social, educational, and government institutions. There may be an indirect relationship between structural racism in the United States and Latino substance use. As such, we explore in this chapter, substance use patterns among individuals identified as Latino and how services and practices that consider the cultural and linguistic backgrounds of Latinos may combat the influence of structural racism on Latino substance use and access to needed treatment.
2. Prevalence of substance use and substance use disorders among Latinos
Among U.S. adults, the rate of illicit drug use during the prior month among persons aged 12 or older was 9.7% among Latinos compared to a national average of 11.7% [6]. Although Latinos have a lower drug use prevalence compared to other racial and ethnic groups in the United States, this level of drug use still has serious consequences for morbidity and mortality among Latinos. Particularly concerning is that the use of illicit drugs continues to increase among Latinos [7]. Regional patterns are also noticeable; in the Southwest, Latinos report more amphetamine use [8], whereas in the Midwest and East, Latinos report increased use of heroin [9].
U.S. Latinos are significantly less likely than Whites to have been diagnosed with a drug use disorder during their lifetime or the prior year [10]. However, during the last 40 years, reported substance use disorders (SUD) among Latinos have continued to increase in the United States [11, 12]. About 20.8 million people aged 12 or older had a SUD during the prior year [13]. SUD among U.S.-born Latinos (18.9%) are more prevalent than among all Latinos (11.3%, [14]). Among U.S. adolescents, Latinos have historically reported similar levels of substance use to those of Whites. In the last few years, however, Latinos have reported the highest rates of use of any illicit drug in 8th, 10th, and 12th grades, primarily due to their increase in marijuana use. Among 12th graders, Latinos have the highest prevalence of use of several substances, including marijuana, synthetic marijuana, inhalants, hallucinogens, LSD, cocaine, crack, methamphetamine, and crystal methamphetamine. Among 8th graders, Latinos report more use of nearly all classes of drugs compared to Whites and African Americans. However, Latino adolescents have a lower prevalence of misusing prescription drugs compared to Whites [15]. Experimenting with any use of substance during early adolescence has been related to a greater likelihood of SUD in adulthood [16, 17, 18].
3. Historical contexts
Throughout history, people of various cultures have used substances for reasons, such as altering or healing the mind [19, 20, 21]. Cultural beliefs have influenced SUD across many racial and ethnic minority groups, including Latinos living in the United States [19, 21]. Substance use behavior is defined as a human behavior motivated by sociocultural beliefs, peer and family influence, and environmental exposure [20]. The general notion is that culture shapes beliefs that lead to behavior and social norms, hence certain cultural beliefs may influence an individual’s motivation to engage in substance use [19]. Cultural beliefs are also embedded in the history of Latinos in North America.
The history of drug use among Latinos has been strongly influenced by the U.S. indigenous nations that have relied on substances to heal several ailments, including abuse of other substances [22]. For example, cannabis has had a long history as both a folk medicine and as an intoxicant. This complex history includes the system of legal control that has been instituted in both the U.S. and Latin American countries to regulate the substance. Another cogent example is a substance derived from peyote, a small spineless cactus, that has been used as a psychoactive drug in Northern Mexico to treat chronic alcohol addiction [23]. Native American churches have also used this substance for the spiritual treatment of chronic alcohol addiction [24]. Many indigenous cultures have used tobacco medicinally and spiritually for thousands of years, whereas in the mainstream U.S. culture, tobacco is considered a recreational and addictive substance [25]. These are important contextual conditions to consider when exploring substance use risk factors among Latino populations.
4. Risk and protective factors for substance use
Many of the risk and protective factors associated with substance use among Latinos are the same factors associated with substance use across multiple racial and ethnic groups, yet acculturation stress, in particular, plays a critical role in the risk of SUD among Latinos. Overall risk factors include substance use by friends or family members, perceived social norms about substance use, access to drugs, psychological comorbidities, impulsive or risk-taking personality traits, and coping skills [26]. Protective factors include antidrug social norms, parental monitoring, and bonding with prosocial mentors and institutions [27]. However, because of their ethnic minority status, immigration histories, and socioeconomic disparities, Latinos also might face additional risk factors for substance use [28]. Especially significant among Latinos is acculturation stress that stems from the circumstances of adapting to the dominant American culture. This persists and is compounded in stressors tied to tensions between the first and succeeding generations within Latino communities. Acculturation stress, which is related to immigrants’ perceptions of discrimination by mainstream Americans, increases the risk of SUD among Latinos [29].
The prevalence of SUD in the Latino population is affected by other psychosocial and emotional factors associated with unemployment, immigration, limited access to education, living in disadvantaged communities, family conflict, and racial and income discrimination [8, 11, 12]. Empirical evidence has revealed interesting relationships with substance use. For instance, Latinos are more likely to use illicit drugs and develop SUD if they do not have a strong connection with their ethnic and cultural background [12, 30, 31]. The importance of family connectedness and living in safe neighborhoods have been emphasized that may contribute to acculturation stress and play a role in Latinos’ substance use [30, 31].
5. Acculturation: U.S. orientation and Latino orientation
Because of the recognition of the centrality of acculturation stress as a risk factor for Latino SUD, a deeper understanding of acculturation is warranted. Most Latinos, even those born in the United States, have some degree of contact or identification with their Latino culture of origin, although this can vary widely across individuals. Latinos living in the United States also have some degree of contact and identification with U.S. culture. The extent to which their practices, values, and identification align with one or both cultures defines their acculturation status [32]. Early theories of acculturation assumed that immigrants replace their heritage culture with a new culture [33]. Later acculturation theories [32] propose that individuals can adopt aspects of the new culture but still identify strongly with the heritage culture. Several studies have concluded that acquisition of U.S. culture is associated with an increased risk of substance use among Latino adolescents [34, 35].
More recent research has drawn a more nuanced conclusion—that the loss of protective aspects of Latino culture, rather than the acquisition of U.S. culture, increase the risk of substance use. Latino adolescents who assimilate into U.S. culture without maintaining a connection to Latino culture are at greater risk of substance use [36] than Latino adolescents who maintain their Latino cultural orientation, especially those who simultaneously participate in U.S. culture and maintain ties with Latino culture [27, 37]. As emphasized above, the role of acculturation stress and rejection from mainstream society plays a central and significant role in Latinos’ higher risk of abusing alcohol and other substances. For example, higher acculturation is related to a higher risk of alcohol and illegal drug abuse as compared to less acculturated Latinos and Whites [38]. Acculturated Latinos reported a 7.2% increase in alcohol and illegal drug use during the previous month, compared to less than 1% of less acculturated Latinos and 6.4% of Whites [38]. Less acculturated Latinos had recently immigrated to the United States and therefore reported higher family values and lower rates of alcohol and drug use [29].
6. Acculturation discrepancies between parents and children
Acculturation occurs in a family system, with adolescents and their parents acculturating at different rates. Immigrant children typically learn and adopt a new culture more rapidly than their parents [33]. Children of immigrants grow up immersed in the receiving culture and are exposed to the heritage culture only secondhand. If families and communities do not maintain and support attributes of the heritage culture, adolescents might reject, forget, or never learn about their culture of origin, leading to acculturation discrepancies between adolescents and parents [33]. Acculturation discrepancies between parents and children can lead to family conflict, which can increase the likelihood that adolescents will experience emotional distress and turn to risky peer groups and risky behaviors in an attempt to cope with that stress [39, 40]. In addition, when parents are less acculturated to U.S. culture than their children, parents must rely on their children for help navigating U.S. culture [41]. This can undermine parental authority, place excessive stress on children, and boost youth’s risk of involvement in problem behaviors, such as substance use [27, 33, 41].
7. Ethnic identity
Ethnic identity includes knowing about one’s ethnic group, perceiving the value and emotional significance of that membership, and feeling a sense of belonging and commitment to the ethnic group [42]. Some studies have shown that a strong ethnic identity protects against substance use [43, 44]. However, this association has been inconsistent across studies, with some finding that a strong ethnic identity is a risk factor for substance use or that no association exists between ethnic identity and substance use [45, 46].
8. Cultural values
Cultural values are attitudes and priorities that are emphasized and encouraged by members of a culture. Endorsement of specific values varies widely across members of a culture, but cultural values are those generally viewed as positive in the culture. For example, individualist cultures encourage and reward outstanding achievements by individuals, whereas collectivist cultures encourage and reward the well-being and prosperity of the group. Certain cultural values might protect against substance use (e.g., obedience to parents, not ingesting intoxicating substances, and regarding one’s body as sacred), whereas other cultural values might increase the risk of substance use (e.g., glamorization of adolescent individualism and rebelliousness, expectations of intoxication in certain social contexts). The Latino cultural value of familism emphasizes the interdependence of family members [47]. This can involve a duty to take care of family members and serve as a resource and role model for family members—responsibilities that tend to be incompatible with substance use. However,
9. Discrimination
Ethnic discrimination is differential treatment based on membership in a minority or lower-status group. It includes overt acts such as violence, harassment by police, discourteous treatment by store clerks, and subtler aggressions such as condescending speech [51]. Ethnic discrimination can be understood as one of the core mechanisms of structural racism. It is through the policies, arrangements, practices, designs, spaces, narrative, and other mechanisms that structural racism gives way to separate, exclude, and ultimately discriminate individuals and/or groups [52]. Perceived discrimination can cause emotional distress, and repeated experiences with discrimination can deplete coping resources and increase the attractiveness of avoidant coping strategies, such as substance use [53]. Perceived discrimination by the dominant culture also can signal to minority group members that they will be blocked from opportunities, which may lead them to identify with oppositional subcultures featuring antisocial norms [54]. Perceptions of discrimination have been associated with the use of tobacco, alcohol, and other substances [55] and with depression [56].
10. Immigration and substance use
Substance abuse has been regarded as a complex phenomenon due to the biological, sociocultural, and historical concepts involved. Therefore, as highlighted above, understanding substance abuse in a target population requires considering its history and context that includes the experience of immigration. This critical factor contributes to substance abuse in Latinos’ complex history that encompasses immigration, migration, or changes of state, such as among Mexicans living in territory acquired by the United States in the early 20th century. These individuals faced new sociocultural values in their host country or new national context. This is most pertinent to Mexicans, who represent more than 65% of the total population of Latinos in the United States [19, 21]. Migration status and experiences are a proxy for the stress, trauma, and potential destitution or disenfranchisement associated with immigrants. Again, this stress has been associated with a higher risk of SUD behaviors.
Previous research indicated that Latinos who move to the United States are more likely to be at risk of illicit substance use compared to those who stay in their home country [38, 57, 58, 59]. Mexican migrants residing in the United States are more likely to experience deficient health care and treatment compared to their U.S.-born Mexican counterparts, specifically women relative to access to treatment [60]. Mexico is one of the largest countries to experience return migration from 2009 to 2012 [61]. Mexicans who migrate to the United States and then return either voluntarily or by deportation for criminal activities to Mexico (i.e., transnational Mexicans) have reported an increased rate of substance use [30, 57, 58, 62, 63].
In addition, transnational Mexicans’ family members (i.e., including relatives who did not migrate) are more likely to use substances (e.g., alcohol, marijuana, and other illicit substances) as compared to other Mexicans [62]. This population often does not seek treatment as readily as Mexicans who did not migrate to the United States [57, 58]. Furthermore, the high risk of substance abuse among transnational Mexicans has negative effects on the quality of life of residents in both countries [58, 64]. Although this may be the case, increasing concern is centered on alcohol and tobacco use among Mexicans living in Mexico [57, 58]. Similarly, compared to men, women reported particular increases in the use of marijuana and cocaine from 2008 to 2011 in Mexico [65].
Marijuana consumption is increasing among adolescents and adults living in Mexico [66]. In Mexico, frequent alcohol use and drinking in large quantities are most common [67]. It appears that this drinking behavior is passed on to adolescents, a substantial number of whom report becoming problem drinkers [68, 69]. Mexico’s National Addictions Survey has shown an increasing proportion of the population needs to seek SUD treatment and learn how to moderate alcohol intake and avoid reoccurring patterns of binge drinking [67].
In Mexico, approximately 13 million Mexicans have reported using at least 100 cigarettes during their lifetime and more than 53,000 deaths occur each year due to tobacco-related diseases [67, 68, 70]. Older adults with higher education are more likely to use tobacco than older adults with a lower education level [71]. Youth are also affected by tobacco use in Mexico because initiation occurs at 13.7 years old on average [67]. This further contributes to the increase in public and social health concerns in Mexico, which have not started to shift away from cigarette use, potentially contributing to an increase in substance use among adolescents [71].
Increasing understanding of how migration affects SUD would help inform epidemiological efforts to reduce substance use behaviors and lead to better treatment outcomes [72]. It is also important to connect translational migrants with their networks and communities to bring about SUD behavior change in the Mexican population [62, 72]. Research has suggested that ecological factors are associated with substance use (e.g., marijuana, other illicit substances; [73]); however, these relationships need to be studied further, specifically in the context of migration [74], family networks, and substance use. Previous studies have recognized that Mexican migrants typically have additional risk factors for substance use, such as low socioeconomic status, immigration status, and social isolation [75, 76]. Therefore, it is still unclear whether substance use is a consequence of the stress of being a Mexican migrant or a manifestation of these other risk factors. This emerging evidence suggests the importance of continuing to explore substance use factors among Mexican transnationals [58] to inform public health efforts to reduce SUD in broad populations, including those in Mexico and the United States. Increasing efforts to understand SUD in other countries will help identify ecological factors and risk factors that affect multiple populations, informing the development and implementation of SUD treatment programs that help alleviate symptoms across a spectrum of populations and communities.
11. Cultural competence in SUD treatment
Latinos have become the fastest-growing population entering SUD treatment, reaching 12% of the total treatment population in the past 10 years [8, 77]. It is important to highlight the need for culturally competent practices and for providers to understand and use clients’ cultural backgrounds, including immigration and acculturation experiences, to support their recovery from SUD. For instance, studies have suggested that among Mexican Americans in the United States, an extended period of residence contributes to a higher prevalence of SUD [78, 79]. Cultural competence may play a critical role in reducing the impact of structural racism in enhancing access to and engagement in the prevention and treatment of Latino substance use [19, 80, 81]. For instance, Latino clients are influenced by individual, program, and community characteristics when facing decisions about substance use and seeking help [7]. As is common with other cultural groups, it is important to establish trust and effective communication to foster positive health outcomes for Latino clients [7]. Engagement occurs through understanding and accepting cultural distinctions, speaking the client’s language, and addressing sociocultural and economic issues related to the problem. In turn, structural racism creates policies, systems, structures, and norms to deny and/or minimize cultural strengths and disempower culturally diverse groups and their attempts to invest in their wellness.
Increasing cultural competence in prevention or treatment improves SUD problems among individuals from various cultural backgrounds [19]. Sociocultural beliefs can influence an individual’s approach to substance use and abuse and further shape treatment options. For Latinos and other racial and ethnic minorities, language barriers and unavailability of bilingual interpreters can also add to long waiting periods to receive treatment [80, 81, 82]. Even further, Latinos and other racial and ethnic minorities experience more difficulties in navigating the health care system as compared to Whites [80]. These findings suggest that it is vital for SUD treatment programs to address the cultural and linguistic needs of their Latino and other minority clients by tailoring services and practices to help achieve better treatment outcomes. Specifically, with diverse populations continuing to increase in the United States, it becomes vital to assess an individual’s substance use and abuse based on his or her racial and ethnic background.
12. Organizational cultural competence
Culturally responsive policies, institutions, communities, and programs can become an intervention to address, decrease and eliminate the creation and use of structural racism. The Office of Minority Health helped in developing standards for healthcare providers to abide by 14 standards (practices) to respond to the cultural and linguistic service needs of diverse populations [83]. Many of the culturally responsive practices have been associated with positive SUD prevention and treatment [80, 84, 85]. For instance, structural, policies, and practices that discriminate against certain groups may be a significant risk of dropout. For culturally and linguistically relevant service outcomes to improve, it is important to identify the methodological flaws of the practices [86]. Cultural competence has been correlated with improved communication, positive therapeutic alliance (e.g., provider-client trust), and higher client satisfaction [80, 87, 88, 89]. In particular, Latinos as well as other racial and ethnic minority clients are more likely to remain in treatment when the services they receive are responsive to their cultural and linguistic needs. Considering the initial evidence suggesting cultural competence can increase the quality of care in SUD prevention and intervention, it is critical to developing nuanced, cost-effective interventions.
13. Training SUD treatment providers in cultural competence
Training staff members to practice cultural competence in SUD treatment is vital to dismantle mechanisms from structural racism that limit clients seeking treatment and improve outcomes. As recently noted in the
It is equally important to instill cultural competence in the organization because this will influence policies and programs and integrate cultural empowerment values and beliefs in the system [92]. A culturally competent organization thrives on bringing diverse individuals together to alter their practices and make them more acceptable across various groups [93]. The organizational outcomes and benefits associated with increasing cultural competence in the organization include improving respect, increasing participation, improving trust and collaboration, and promoting equality [92, 93]. Organizations can become culturally competent by seeking collaboration with individuals from various racial and ethnic backgrounds and further identifying the needs of these groups [94]. Identifying those needs provides a space to better adapt and learn how organizations can meet the demands of their diverse clients.
14. Cultural competence applied to different treatment modalities
The importance of applying cultural competence to various settings and organizations is increasing. It is becoming the norm to request that professionals be culturally competent in the health care system [95]. Culturally competent environments are rapidly growing in organizations. For instance, culturally competent models are being applied to cognitive behavioral therapy as a means of improving outcomes in treatment among minority groups, such as Latinos [96]. This is achieved by providing bilingual translators and programs to Latino clients and training staff members to be respectful of their cultural backgrounds. This has led to the development of mutually respectful and cooperative relationships between clients and their providers.
Cultural competence has been applied to interventions that focus on individuals with depression to improve treatment outcomes among racial and ethnic minority groups [97]. In fact, culturally competent adaptations to psychotherapy have been found to be more effective in reducing symptoms of mental conditions (e.g., depression) as compared to a wait-list control group [97, 98]. Professions that have focused on including cultural competence in their work environment include business, social work, psychology, public relations, education, and health care [99, 100, 101, 102].
15. Cultural competence in the community
Aside from improving cultural competence in organizations, it is equally important to focus these efforts on refining communities. With minority populations migrating to different communities in the United States, there is an urgent need to make communities more inclusive (e.g., increase awareness of implicit bias and understanding of groups’ needs through CLAS and other culturally responsive practices) toward diverse populations [103]. This diversity and inclusion may help mitigate some of the psychosocial stresses related to SUD among minority populations. Access to treatment for clients is usually available in their own neighborhoods and communities, and therefore it is critical for SUD treatment programs to adopt a community approach to cultural competence. Mounting evidence suggests that programs with greater knowledge and investment in minority communities are more likely to increase access to care [104]. Programs investing in communities of color may also benefit some of the most vulnerable members of society, such as homeless individuals [105].
Clients with SUD issues should feel comfortable accessing providers in their own communities that offer a safe and acceptable space for them to seek health care options. Efforts should be made to culturally integrate communities to develop programs and policies that are meaningful for diverse populations and to ensure cultural values are shared across the population [103, 106]. Cultural competence in the community setting could lead to the inclusion of community members and even increased participation and involvement in community issues [103]. Cultural competence could lead to numerous benefits from the individual to the communal level and lead to improved health outcomes by increasing understanding, acceptance, and respect for diverse clients and their communities [107].
16. Conclusion and future directions
The evidence provided in this chapter suggests that Latinos, as the largest ethnic minority group in the U.S., have a distinctive history of substance use and help-seeking behaviors. The socialization of substance use in their lives and the role of substances in their history of immigration, for instance, are important issues that may be impacted by structural racism. The prevalence of SUD in Latinos is affected by factors, such as unemployment, acculturation stress, and discrimination. Discrimination, in terms of exclusive prevention and treatment policies and practices by funders, regulators, and service providers, maybe one of the most critical factors contributing to SUD. A clear example is the bifurcated opioid treatment system, where low income and publicly insured Latinos are more likely to receive methadone, while mid- and high-income non-Latino Whites are more likely to receive buprenorphine, a medication with significant advantages to obtain, impact, and side effects.
Latinos have also distinctive prevalence rates regarding the use of specific substances. Some of these substances are more accessible in some regions of the United States. Latino adolescents also have unique primary substances of choice (e.g., marijuana and methamphetamine) compared to adults, and the prevalence of use among these youth reflects their developmental stage, with much higher use during thrill-seeking ages that decreases as adolescents age. Overall, ecological factors, such as family, employment, migration, and discrimination, play an important role in Latino substance use and need to be studied further.
Cultural competence has become a critical approach to understand and respond to the substance use disorder issues experienced by groups vulnerable to discrimination and/or racism. In the past 30 years, research in the definition, operationalization, and assessment of this concept has slowly gained attention because of its potential to improve prevention and interventions to address SUD. But significant challenges remain to implement culturally responsive practices in social, educational, and government institutions to reduce acculturation stress related to Latino substance use and access to SUD treatment. Additional research is needed to establish the impact of key components of culturally responsive practices (e.g., inclusive policies, matching provider and clients based on language and cultural background) with different areas that support minorities achieving sobriety.
Future research is needed to understand the risk and protective factors for problematic substance use and treatment access among Latino migrants and future generations of Latinos living in the United States and intervene with structural factors, such as immigration and inclusive policies and responsive organizational practices to improve Latino health. If resilience factors can be identified and encouraged, addiction and its adverse medical and social consequences can be reduced. Latinos have become the fastest-growing population entering SUD treatment. The distinctive nature of Latinos’ patterns of substance use, substance of choice, co-occurring mental and primary care issues, and barriers to access care highlights the importance of developing and implementing culturally informed interventions that consider clients’ background, immigration experience, and linguistic service needs to help reduce substance abuse among Latinos. Policies and practices that are culturally responsive also referred to as antiracist may have the foundation and drive to have a significant impact on eliminating disparities and promoting the health equity that Latinos have long deserved.
References
- 1.
U.S. Census Bureau. Latino Heritage Month. 2014. Available from: https://www.census.gov/eeo/special_emphasis_programs/Latino_heritage.html - 2.
U.S. Census Bureau. Census Redistricting Data. 2020. Available from: from https://www.census.gov/library/visualizations/interactive/racial-and-ethnic-diversity-in-the-united-states-2010-and-2020-census.html - 3.
U.S. Census Bureau. Income and Poverty in the United States: 2020. Washington, DC: U.S. Government Publishing Office; 2021 - 4.
Pew Latino Center. (2013). Latino Population in Select U.S. Metropolitan Areas, 2011. Available from: http://www.pewLatino.org/2013/08/29/Latino-population-in-select-u-s-metropolitan-areas-2011/ - 5.
Fry R, Passel JS. Latino Children: A Majority Are U.S.-Born Offspring of Immigrants. Washington, DC: Pew Latino Center; 2009 - 6.
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health (NSDUH). NSDUH; 2019. Available from: https://www.samhsa.gov/data/population-data-nsduh - 7.
Substance Abuse and Mental Health Services Administration. Improving Cultural Competence (Treatment Improvement Protocol Series No. 59, HHS Publication No. SMA 14-4849). Rockville, MD: Author; 2014 - 8.
Guerrero EG, Marsh JC, Duan L, Oh C, Perron B, Lee B. Disparities in completion of substance abuse treatment between and within racial and ethnic groups. Health Services Research. 2013; 48 :1450-1467. DOI: 10.1111/1475-6773.12031 - 9.
Substance Abuse and Mental Health Services Administration. 2015 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Author; 2016 - 10.
Grant BF, Saha TD, Ruan WJ, Goldstein RB, Chou SP, Jung J, et al. Epidemiology of DSM-5 drug use disorder: Results from the National Epidemiologic Survey on alcohol and related conditions-III. JAMA Psychiatry. 2016; 73 :39-47. DOI: 10.1001/jamapsychiatry.2015.2132 - 11.
Guerrero EG, Marsh JC, Khachikian T, Amaro H, Vega WA. Disparities in Latino substance use, service use, and treatment: Implications for culturally and evidence-based interventions under health care reform. Drug and Alcohol Dependence. 2013; 133 :805-813. DOI: 10.1016/j.drugalcdep.2013.07.027 - 12.
Salas-Wright CP, Clark TT, Vaughn MG, Córdova D. Profiles of acculturation among Latinos in the United States: Links with discrimination and substance use. Social Psychiatry and Psychiatric Epidemiology. 2015; 50 :39-49. DOI: 10.1007/s00127-014-0889-x - 13.
Center for Behavioral Health Statistics and Quality. Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). 2016. Available from: https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.pdf - 14.
Alegría M, Canino G, Shrout PE, Woo M, Duan N, Vila D, et al. Prevalence of mental illness in immigrant and non-immigrant U.S. Latino groups. American Journal of Psychiatry. 2008; 165 :359-369. DOI: 10.1176/appi.ajp.2007.07040704 - 15.
Johnston LD, O’Malley PM, Miech RA, Bachman JG, Schulenberg JE. Monitoring the Future National Survey Results on Drug Use, 1975-2016: Overview, Key Findings on Adolescent Drug Use. Ann Arbor: University of Michigan, Institute for Social Research; 2017 - 16.
Agrawal A, Lynskey MT, Pergadia ML, Bucholz KK, Heath AC, Martin NG, et al. Early cannabis use and DSM-IV nicotine dependence: A twin study. Addiction. 2008; 103 :1896-1904. DOI: 10.1111/j.1360-0443.2008.02354.x - 17.
D’Amico EJ, Ellickson PL, Collins RL, Martino S, Klein DJ. Processes linking adolescent problems to substance-use problems in late young adulthood. Journal of Studies on Alcohol. 2005; 66 :766-775. DOI: 10.15288/jsa.2005.66.766 - 18.
Englund MM, Egeland B, Oliva EM, Collins WA. Childhood and adolescent predictors of heavy drinking and alcohol use disorders in early adulthood: A longitudinal developmental analysis. Addiction. 2008; 103 :23-35. DOI: 10.1111/j.1360-0443.2008.02174.x - 19.
Heath DB. Culture and substance abuse. Psychiatric Clinics of North America. 2001; 24 :479-496. DOI: 10.1016/S0193-953X(05)70242-2 - 20.
Jiloha RC. Social and cultural aspects of drug abuse in adolescents. Delhi Psychiatry Journal. 2009; 12 :167-175 - 21.
Westermeyer J. Cross-cultural aspects of substance abuse. In: Galanter M, Kleber HD, editors. The American Psychiatric Publishing Textbook of Substance Abuse Treatment. Arlington, VA: American Psychiatric Publishing; 2004. pp. 89-98 - 22.
Campos I. Home Grown: Marijuana and the Origins of the Mexico’s Drug War on Drugs. North Carolina: University of North Carolina Press; 2014 - 23.
Schultes RE. The appeal of peyote (Lophophora williamsii) as a medicine. American Anthropologist. 1938; 40 :698-715. DOI: 10.1525/aa.1938.40.4.02a00100 - 24.
Le Barre W. The Peyote Cult. Hamden, Connecticut: Shoe String Press; 1964 - 25.
Unger JB, Soto C, Baezconde-Garbanati L. Perceptions of ceremonial and nonceremonial uses of tobacco by American-Indian adolescents in California. Journal of Adolescent Health. 2006; 38 :443.e9-443.e16. DOI: 10.1016/j.jadohealth.2005.02.002 - 26.
Schinke S, Schwinn T, Hopkins J, Wahlstrom L. Drug abuse risk and protective factors among Latino adolescents. Preventive Medicine Reports. 2016; 3 :185-188. DOI: 10.1016/j.pmedr.2016.01.012 - 27.
Szapocznik J, Prado G, Burlew AK, Williams RA, Santisteban DA. Drug abuse in African American and Latino adolescents: Culture, development, and behavior. Annual Review of Clinical Psychology. 2007; 3 :77-105. DOI: 10.1146/annurev.clinpsy.3.022806.091408 - 28.
Yu M, Chavez PE, Olate R, Peters C. Cigarette smoking status among Latino/Hispanic middle and high school students in the United States. Substance Use & Misuse. 2017; 52 (3):303-312. DOI: 10.1080/10826084.2016.1225763 - 29.
Cervantes RC, Gattamorta KA, Berger-Cardoso J. Examining difference in immigration stress, acculturation stress and mental health outcomes in six Hispanic/Latino nativity and regional groups. Journal of Immigrant and Minority Health. 2019; 21 (1):14-20 - 30.
Borges G, Breslau J, Orozco R, Tancredi DJ, Anderson H, Aguilar-Gaxiola S, et al. A cross-national study on Mexico-US migration, substance use and substance use disorders. Drug and Alcohol Dependence. 2011; 117 :16-23. DOI: 10.1016/j.drugalcdep.2010.12.022 - 31.
Savage JE, Mezuk B. Psychosocial and contextual determinants of alcohol and drug use disorders in the National Latino and Asian American study. Drug and Alcohol Dependence. 2014; 139 :71-78. DOI: 10.1016/j.drugalcdep.2014.03.011 - 32.
Schwartz SJ, Unger JB, Zamboanga BL, Szapocznik J. Rethinking the concept of acculturation: Implications for theory and research. American Psychologist. 2010; 65 (4):237-251. DOI: 10.1037/a0019330 - 33.
Portes A, Rumbaut RG. Legacies: The Story of the Immigrant Second Generation. Berkeley, CA: University of California Press; 2001 - 34.
Cherpitel CJ, Borges G. A comparison of substance use and injury among Mexican American emergency room patients in the United States and Mexicans in Mexico. Alcoholism: Clinical & Experimental Research. 2001; 25 :1174-1180. DOI: 10.1111/j.1530-0277.2001.tb02332.x - 35.
De La Rosa MR, Khalsa JH, Rouse BA. Latino and illicit drug use: A review of recent findings. International Journal of the Addictions. 1990; 25 :665-691. DOI: 10.3109/10826089009061327 - 36.
De La Rosa MR. Acculturation and Latino adolescents’ substance use: A research agenda for the future. Substance Use & Misuse. 2002; 37 :429-456. DOI: 10.1081/JA-120002804 - 37.
Bacallao ML, Smokowski PR. “Entre dos mundos” (between two worlds): Bicultural skills training with Latino immigrant families. Journal of Primary Prevention. 2005; 26 :485-509. DOI: 10.1007/s10935-005-0008-6 - 38.
Rodriguez RA, Henderson CE, Rowe CL, Burnett KF, Dakof GA, Liddle HA. Acculturation and drug use among dually diagnosed Latino adolescents. Journal of Ethnicity in Substance Abuse. 2007; 6 :97-113. DOI: 10.1300/J233v06n02_07 - 39.
Lorenzo-Blanco EI, Unger JB, Baezconde-Garbanati L, Ritt-Olson A, Soto D. Acculturation, enculturation, and symptoms of depression in Latino youth: The roles of gender, Latino cultural values, and family functioning. Journal of Youth and Adolescence. 2012; 41 :1350-1365. DOI: 10.1007/s10964-012-9774-7 - 40.
Lorenzo-Blanco EI, Unger JB, Ritt-Olson A, Soto D, Baezconde-Garbanati L. Acculturation, gender, depression, and cigarette smoking among U.S. Latino youth: The mediating role of perceived discrimination. Journal of Youth and Adolescence. 2011; 40 :1519-1533. DOI: 10.1007/s10964-011-9633-y - 41.
Titzmann PF. Growing up too soon? Parentification among immigrant and native adolescents in Germany. Journal of Youth and Adolescence. 2012; 41 :880-893. DOI: 10.1007/s10964-011-9711-1 - 42.
Phinney JS. Ethnic identity in adolescents and adults: Review of research. Psychological Bulletin. 1990; 108 :499-514. DOI: 10.1037/0033-2909.108.3.499 - 43.
Brook JS, Zhang C, Finch SJ, Brook DW. Adolescent pathways to adult smoking: Ethnic identity, peer substance use, and antisocial behavior. American Journal on Addictions. 2010; 19 - 44.
Marsiglia FF, Kulis S, Hecht ML, Sills S. Ethnicity and ethnic identity as predictors of drug norms and drug use among preadolescents in the US southwest. Substance Use & Misuse. 2004; 39 :1061-1094. DOI: 10.1081/JA-120038030 - 45.
Kulis SS, Marsiglia FF, Kopak AM, Olmsted ME, Crossman A. Ethnic identity and substance use among Mexican-heritage preadolescents: Moderator effects of gender and time in the United States. Journal of Early Adolescence. 2012; 32 :165-199. DOI: 10.1177/0272431610384484 - 46.
Zamboanga BL, Schwartz SJ, Jarvis LH, Van Tyne K. Acculturation and substance use among Latino early adolescents: Investigating the mediating roles of acculturative stress and self-esteem. Journal of Primary Prevention. 2009; 30 :315-333. DOI: 10.1007/s10935-009-0182-z - 47.
Cuéllar I, Arnold B, González G. Cognitive referents of acculturation: Assessment of cultural constructs in Mexican Americans. Journal of Community Psychology. 1995; 23 :339-356. DOI: 10.1002/1520-6629(199510)23:4<339::AID-JCOP2290230406>3.0.CO;2-7 - 48.
Garcia W. Respeto: A Mexican base for interpersonal relationships. In: Gudykunst WB, Ting-Toomey S, Nishida T, editors. Communication in Personal Relationships across Cultures. Thousand Oaks, CA: Sage; 1996. pp. 137-155 - 49.
Unger JB, Ritt-Olson A, Teran L, Huang T, Hoffman BR, Palmer P. Cultural values and substance use in a multiethnic sample of California adolescents. Addiction Research & Theory. 2002; 10 :257-279. DOI: 10.1080/16066350211869 - 50.
Unger JB, Shakib S, Gallaher P, Ritt-Olson A, Mouttapa M, Palmer PH, et al. Cultural/interpersonal values and smoking in an ethnically diverse sample of Southern California adolescents. Journal of Cultural Diversity. 2006; 13 :55-63 - 51.
Williams DR, Neighbors HW, Jackson JS. Racial/ethnic discrimination and health: Findings from community studies. American Journal of Public Health. 2008; 98 :S29-S37. DOI: 10.2105/AJPH.98.Supplement_1.S29 - 52.
Gee G, Ford C. Structural racism and health inequities: Old issues, new directions. Du Bois Review: Social Science Research on Race. 2011; 8 (1):115-132. DOI: 10.1017/S1742058X11000130 - 53.
Krieger N. Discrimination and health. In: Berkman LF, Kawachi I, editors. Social Epidemiology. New York, NY: Oxford University Press; 2000. pp. 36-75 - 54.
Ogbu J. Immigrant and involuntary minorities in comparative perspective. In: Gibson M, Ogbu J, editors. Minority Status and Schooling: A Comparative Study of Immigrant and Involuntary Minorities. New York, NY: Garland; 1991. pp. 184-204 - 55.
Okamoto J, Ritt-Olson A, Soto D, Baezconde-Garbanati L, Unger JB. Perceived discrimination and substance use among Latino adolescents. American Journal of Health Behavior. 2009; 33 :718-727. DOI: 10.5993/AJHB.33.6.9 - 56.
Greene ML, Way N, Pahl K. Trajectories of perceived adult and peer perceived discrimination among Black, Latino, and Asian American adolescents: Patterns and psychological correlates. Developmental Psychology. 2006; 42 :218-236. DOI: 10.1037/0012-1649.42.2.218 - 57.
Guerrero EG, Villatoro JA, Kong Y, Fleiz C, Vega WA, Strathdee SA, et al. Barriers to accessing substance abuse treatment in Mexico: National comparative analysis by migration status. Substance Abuse Treatment, Prevention, and Policy. 2014; 9 :30. DOI: 10.1186/1747-597X-9-30 - 58.
Guerrero EG, Villatoro JA, Kong Y, Gamiño MB, Vega WA, Medina Mora ME. Mexicans’ use of illicit drugs in an era of drug reform: National comparative analysis by migrant status. International Journal of Drug Policy. 2014; 25 :451-457. DOI: 10.1016/j.drugpo.2014.04.006 - 59.
Myers R, Chou C-P, Sussman S, Baezconde-Garbanati L, Pachon H, Valente TW. Acculturation and substance use: Social influence as a mediator among Latino alternative high school youth. Journal of Health and Social Behavior. 2009; 50 :164-179. DOI: 10.1177/002214650905000204 - 60.
Zemore SE, Mulia N, Ye Y, Borges G, Greenfield TK. Gender, acculturation, and other barriers to alcohol treatment utilization among Latinos in three national alcohol surveys. Journal of Substance Abuse Treatment. 2009; 36 :446-456. DOI: 10.1016/j.jsat.2008.09.005 - 61.
Massey DS, Pren KA. Origins of the new Latino underclass. Race and Social Problems. 2012; 4 :5-17. DOI: 10.1007/s12552-012-9066-6 - 62.
Borges G, Medina-Mora ME, Breslau J, Aguilar-Gaxiola S. The effect of migration to the United States on substance use disorders among returned Mexican migrants and families of migrants. American Journal of Public Health. 2007; 97 :1847-1851. DOI: 10.2105/AJPH.2006.097915 - 63.
Wagner KD, Pollini RA, Patterson TL, Lozada R, Ojeda VD, Brouwer KC, et al. Cross-border drug injection relationships among injection drug users in Tijuana, Mexico. Drug and Alcohol Dependence. 2011; 113 :236-241. DOI: 10.1016/j.drugalcdep.2010.08.009 - 64.
Wagner KD, Moynihan MJ, Strathdee SA, Cuevas-Mota J, Clark M, Zúñiga ML, et al. The social and environmental context of cross-border drug use in Mexico: Findings from a mixed methods study of young injection drug users living in San Diego, CA. Journal of Ethnicity in Substance Abuse. 2012; 11 :362-378. DOI: 10.1080/15332640.2012.735182 - 65.
Villatoro J, Medina-Mora ME, Fleiz BC, Moreno LM, Oliva RN, Bustos GM, et al. El consumo de drogas en México: Resultados de la Encuesta Nacional de Adicciones, 2011. Salud Mental. 2012; 35 :447-457 - 66.
Villatoro VJA, Mendoza MMA, Moreno LM, Oliva RN, Fregoso ID, Bustos GM, et al. Tendencias del uso de drogas en la Ciudad de México: Encuesta de estudiantes, Octubre 2012. Salud Mental. 2014; 37 :423-435 - 67.
Instituto Nacional de Salud Pública. Encuesta Nacional de Adicciones 2008. Cuernavaca, Mexico: Author; 2008 - 68.
Fabelo JR, Iglesias S, Cabrera R, Maldonado MT. Tobacco and alcohol consumption among health sciences students in Cuba and Mexico. MEDICC Review. 2013; 15 (4):18-23 - 69.
Ministerio de Salud Pública. Programa nacional de salud para la atención integral diferenciada en la adolescencia. Havana, Cuba: Author; 2012 - 70.
de Salud S. Observatorio Mexicano en tabaco, alcohol y otras drogas 2003. Mexico City, Mexico: Author; 2004 - 71.
Wong R, Ofstedal MB, Yount K, Agree EM. Unhealthy lifestyles among older adults: Exploring transitions in Mexico and the US. European Journal of Ageing. 2008; 5 :311-326. DOI: 10.1007/s10433-008-0098-0 - 72.
Borges G, Medina-Mora M-E, Orozco R, Fleiz C, Cherpitel C, Breslau J. The Mexican migration to the United States and substance use in northern Mexico. Addiction. 2009; 104 :603-611. DOI: 10.1111/j.1360-0443.2008.02491.x - 73.
Delva J, Lee W, Sanchez N, Andrade FH, Grogan-Kaylor A, Sanhueza G, et al. Ecological factors and adolescent marijuana use: Results of a prospective study in Santiago, Chile. International Journal of Environmental Research and Public Health. 2014; 11 :3443-3452. DOI: 10.3390/ijerph110303443 - 74.
Massey DS. Immigration policy mismatches and counterproductive outcomes: Unauthorized migration to the U.S. in two eras. Comparative Migration Studies. 2020; 8 :21. DOI: doi.org/10.1186/s40878-020-00181-6 - 75.
Mora J. Latinas in cultural transition: Addiction, treatment and recovery. In: Straussner SLA, Brown S, editors. The Handbook of Addiction Treatment for Women: Theory and Practice. San Francisco, CA: Jossey-Bass; 2002. pp. 323-347 - 76.
Valdez A, Kaplan CD, Cepeda A. The process of paradoxical autonomy and survival in the heroin careers of Mexican American women. Contemporary Drug Problems. 2000; 27 :189-212. DOI: 10.1177/009145090002700108 - 77.
Guerrero EG. Managerial capacity and adoption of culturally competent practices in outpatient substance abuse treatment organizations. Journal of Substance Abuse Treatment. 2010; 39 :329-339. DOI: 10.1016/j.jsat.2010.07.004 - 78.
Borges G, Cherpitel CJ, Orozco R, Zemore SE, Wallisch L, Medina-Mora M-E, et al. Substance use and cumulative exposure to American society: Findings from both sides of the US–Mexico border region. American Journal of Public Health. 2016; 106 :119-127. DOI: 10.2105/AJPH.2015.302871 - 79.
Grant BF, Stinson FS, Hasin DS, Dawson DA, Chou SP, Anderson K. Immigration and lifetime prevalence of DSM-IV psychiatric disorders among Mexican Americans and non-Latino whites in the United States: Results from the National Epidemiologic Survey on alcohol and related conditions. Archives of General Psychiatry. 2004; 61 :1226-1233. DOI: 10.1001/archpsyc.61.12.1226 - 80.
Guerrero EG, Andrews CM. Cultural competence in outpatient substance abuse treatment: measurement and relationship with wait time and retention. Drug and Alcohol Dependence. 2011; 119 :e13-e22 - 81.
González H, Vega WA, Tarraf W. Health care quality perceptions among foreign-born Latinos and the importance of speaking the same language. Journal of the American Board of Family Medicine. 2010; 23 :745-752 - 82.
Betancourt JR. Eliminating racial and ethnic disparities in health care: What is the role of academic medicine? Academic Medicine. 2006; 81 (9):788-792 - 83.
Narayan MC. The national standards for culturally and linguistically appropriate services in health care. Care Management Journals. 2002; 3 (2):77-83 - 84.
Grella CE. Women in residential drug treatment: Differences by program type and pregnancy. Journal of Health Care for the Poor Underserved. 1999; 10 :216-229 - 85.
Zhang Z, Friedmann PD, Gerstein DR. Does retention matter? Treatment duration and improvement in drug use. Addiction. 2003; 98 :673-684 - 86.
Fisher TL, Burnet DL, Huang ES, Chin MH, Cagney KA. Cultural leverage: Interventions using culture to narrow racial disparities in health care. Medical Care Research and Review. 2007; 64 (5 Suppl):243S-282S. doi: 10.1177/1077558707305414 - 87.
Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Managed Care Research and Review. 2000; 57 ( Suppl. 1):181-217. DOI: 10.1177/1077558700057001S09 - 88.
González HM, Vega WA, Tarraf W. Health care quality perceptions among foreign-born Latinos and the importance of speaking the same language. Journal of the American Board of Family Medicine. 2010; 23 :745-752 - 89.
Saha S, Taggart SH, Komaromy M, Bindman AB. Do patients choose physicians of their own race? Health Affairs. 2000; 19 :76-83. DOI: 10.1111/j.1530-0277.2000.tb04571.x - 90.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: Author; 2013 - 91.
Robin RW, Saremi A, Albaugh B, Hanson RL, Williams D, Goldman D. Validity of the SMAST in two American Indian tribal populations. Substance Use & Misuse. 2004; 39 :601-624. DOI: 10.1081/JA-120030062 - 92.
Harper M, Hernandez M, Nesman T, Mowery D, Worthington J, Isaacs M. Organizational Cultural Competence: A Review of Assessment Protocols (FMHI Pub. No. 240-2). Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, Research & Training Center for Children’s Mental Health; 2006 - 93.
Hofstede G. Culture and Organizations: Software of the Mind. New York, NY: McGraw-Hill; 1997 - 94.
Harper W, Cook S, Makoul G. Teaching medical students about health literacy: 2, Chicago initiatives. American Journal of Health Behavior. 2007; 31 :S111-S114 - 95.
Herman KC, Merrell KW, Reinke WM, Tucker CM. The role of school psychology in preventing depression. Psychology in Schools. 2004; 41 (7):763-775 - 96.
Miranda J, Azocar F, Organista K, Dwyer E, Areane P. Treatment of depression among impoverished primary care patients from ethnic minority groups. Psychiatric Services. 2003a; 54 :219-225. DOI: 10.1176/appi.ps.54.2.219 - 97.
Miranda J, Duan N, Sherbourne C, Schoenbaum M, Lagomasino I, Jackson-Triche M, et al. Improving care for minorities: Can quality improvement interventions improve care and outcomes for depressed minorities? Results of a randomized, controlled trial. Health Services Research. 2003; 38 :613-630. DOI: 10.1111/1475-6773.00136 - 98.
Rosselló J, Bernal G, Rivera-Medina C. Individual and group CBT and IPT for Puerto Rican adolescents with depressive symptoms. Cultural Diversity and Ethnic Minority Psychology. 2008; 14 :234-245. DOI: 10.1037/1099-9809.14.3.234 - 99.
Craig S, Hull K, Haggart AG, Perez-Selles M. Promoting cultural competence through teacher assistance teams. Teaching Exceptional Children. 2000; 32 (3):6-12. DOI: 10.1177/004005990003200302 - 100.
Doutrich D, Storey M. Education and practice: Dynamic partners for improving cultural competence in public health. Family and Community Health. 2004; 27 :298-307. DOI: 10.1097/00003727-200410000-00006 - 101.
Johnston ME, Herzig RM. The interpretation of “culture”: Diverging perspectives on medical provision in rural Montana. Social Science & Medicine. 2006; 63 :2500-2511. DOI: 10.1016/j.socscimed.2006.06.013 - 102.
National Association of Social Workers. NASW Standards for Cultural Competence in Social Work Practice. Washington, DC: Author; 2001 - 103.
Bennett WL. News: The Politics of Illusion. 6th ed. Boston, MA: Pearson Education; 2005 - 104.
Guerrero EG, Fenwick K, Kong Y, Grella C, D’Aunno T. Paths to improving engagement among racial and ethnic minorities in addiction health services. Substance Abuse Treatment, Prevention, and Policy. 2015; 10 :40. DOI: 10.1186/s13011-015-0036-z - 105.
Guerrero EG, Song A, Henwood B, Kong Y, Kim T. Response to culturally competent drug treatment among homeless persons with different living arrangements. Evaluation and Program Planning. 2018; 66 :63-69 - 106.
Wells MI. Beyond cultural competence: A model for individual and institutional cultural development. Journal of Community Health Nursing. 2000; 17 :189-199. DOI: 10.1207/S15327655JCHN1704_1 - 107.
Wilson-Stronks A, Mutha S. From the perspective of CEOs: What motivates hospitals to embrace cultural competence? Journal of Healthcare Management. 2010; 55 :339-352