In this section, you’ll learn more about how health disparities, myths, stigma, and implicit bias can erect additional barriers to recovery and the cultural competencies peer support specialists develop to help people overcome them. Finally, this section highlights examples of different cultural healing traditions that support recovery. Once you have completed this section, you should be able to:
- Give examples of health disparities that affect individuals with mental health or addictive disorders from underserved groups.
- List the laws that protect people with mental health and substance use disorders from discrimination.
What are health disparities?
When it comes to mental health and addictive disorders, deep disparities have existed for far too many years that affect women, African and Indigenous Americans, Americans of Latin or Spanish ancestry, immigrants and refugees, the poor, and LGBTQ+ individuals, to name a few. Despite recent efforts, these biases still influence how and if people are diagnosed, who receives treatment and what type, the medications they are prescribed, whose behavior is viewed as criminal, and whose as merely non-compliant.
Health disparities affecting people with mental health and addictive disorders
| Life expectancy | According the CDC National Center for Health Statistics, US life expectancy had the largest decrease in 2020 since WWII. Although life expectancy declined twice during prior peak years of the opioid crisis (2015 & 2017), COVID-19 was largely responsible for the decline, but drug overdose deaths also contributed. Below are racial and ethnic disparities in decreased years of life expectancy:
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| Drug overdose fatalities | According to CDC, stimulant overdose deaths among African and Indigenous Americans increased 45% in 2020. Methamphetamine involvement in deaths among all minority populations increased, except African Americans, for whom cocaine involvement in fatalities is increasing, despite usage rates less than or equal to cocaine use among Whites.
Rates of overdose deaths among Indigenous Americans are highest and continue to exceed fatality rates among Whites; however, 2020 rates of overdose deaths among African Americans exceeded rates among Whites for the first time since 1999 (Friedman et. al, 2022). |
| Impact of incarceration on life expectancy | In a nationally representative, sample of 7,974 individuals who were followed up for nearly 4 decades, researchers found that experiencing an incarceration in adulthood was associated with lower life expectancy for Black but not for non-Black participants (Bovell-Ammon et. al, 2022). |
| Mass incarceration and its consequences | In 2009, one in every nine Black children had a parent in prison, as compared to 1 in every 57 White children, contributing to disproportionate health behavioral and physical risks among Black children. Recent data indicates modest improvement (now one in ten) (Nellis, 2021).
Blacks are at least 13 times more likely to be arrested for buying and using drugs. The US Sentencing Commission found that Blacks received longer prison sentences for drug-related offenses than other races convicted for crimes of similar weight. Bureau of Justice Statistics reported that in 2012, 45% of the 225,242 state prison inmates serving sentences for drug-related offenses were Black (Griffith et. al 2019). About 80% of those convicted of heroin trafficking are either Black or Latino, even though Whites use opioids at higher rates than other groups and tend to buy drugs from their own racial group (James and Jordon, 2018). |
| Alternatives to incarceration/diversion programs | Black arrestee, probation, and custody populations are up to 20% underrepresented in drug court programs as compared to Whites; Hispanics are up to 15% underrepresented (Marlow, 2013). Black, Hispanic, and female drug court participants are less likely to successfully complete drug court programs than White male participants (completion rates differed by 25% to 45%) (Gallagher and Wahler, 2019).
In 2016-2017, rural counties in the Northern Central region of the US accepted 74% of Whites referred to drug court programs but only 24% of Black referrals (Marlowe, 2022). |
| OUD Treatment | Whites involved with the criminal justice system are more likely to have their OUD treatment paid by a court (10%) relative to Blacks (4.0%); OUD treatment for 77% Blacks is paid for by public insurance (vs 36% of Whites).
Research suggests prevalence of opioid misuse is lower among Blacks (3.5%) as compared to Whites (4.7%) (SAMHSA, 2017). Despite increases in overdose deaths among Blacks, access to office-based opioid treatment (OBOT) with buprenorphine is low, with physicians in private practice more likely to prescribe buprenorphine to Whites with private insurance or ability to self-pay (Agency for Healthcare Research and Quality, 2018). |
| Impact of discrimination and trauma | Black adults with major depression continue to experience greater persistence, along with discrimination, racism, and disparities in access to quality of mental health services (Flores et. al, 2021). Black adults with drug problems reported similar experiences in primary care settings (Bernstein et. al, 2017). Culturally responsive peer support for minoritized racial and ethnic groups recognizes the impact of discrimination and trauma, including those that stem from interactions medical and behavioral health care services (Cook et. al, 2019). |
The Role of Peers in Reducing Disparities
According to the Substance Abuse & Mental Health Services administration, supporting recovery requires mental health and addiction services to: “Be responsive and respectful to the health beliefs, practices, and cultural and linguistic needs of diverse people and groups. Actively address diversity in the delivery of services. Seek to reduce health disparities in access and outcomes.”
One part of the above statement that is especially important for peer support specialists is reducing disparities in access and outcomes. The growth and expansion of a diverse and inclusive CA peer support specialist workforce has great potential to increase access, but achieving equity also means looking at outcomes. In other words, equitable care means not only ensuring equal access to services, but also ensuring the services do the job equally well for all.
The added ethical mandate for inclusiveness should not just fall on the shoulders of peer support specialists of color or from other subgroups that experience the consequences of health disparities, but rather all peer support specialists must work to acquire competencies that will help them deliver the most culturally responsive services possible to all.
Only commitment and consistent advocacy on behalf of the individuals we serve will help to make sure the disparities of the past don’t dictate the future of peer support services. Making cultural diversity, equity, and inclusion a priority and increasing our competencies in these areas can continue move us closer to a culturally responsive peer recovery movement.
Peer support services have played an important role in reducing some of these disparities. Because peer support services emerge out of unmet in within communities, they have often given voice to individuals and groups who encounter barriers when they seek services from more conventional systems of care. It is critical to recruit, empower, and maintain a diverse peer recovery workforce, especially considering current data on overdose death showing disproportionate increases among youth, and Indigenous and African American youth and adults in California.
Peer support specialists from underserved communities and subgroups can play an important role as trusted messengers of harm reduction resources and practices that can help save lives in underserved communities with disproportionate rates of overdose deaths. In some communities, the stigma associated with mental health and addictive disorders is greater or it conspires with existing disparities to erect more barriers to recovery.
Why is Culture Important to Peers?
An individual’s identity is grounded in their culture, but people are complex and may identify with many different cultural groups and subgroups. However, only a certain number of those groups and subgroups experience health disparities rooted in gender- or race-based bias and other forms of discrimination that contribute to the pockets of historically underserved communities that persist in the US.
Moreover, many of those same subgroups have certain needs that ‘mainstream’ services do not always accommodate. If we substitute ‘dominant culture’ for ‘mainstream,’ the issue and its connection with culture is more apparent. Various cultures may ascribe different levels of stigma to certain health risk behaviors and conditions associated with mental health and addictive disorders. They may also value culturally specific recovery pathways and healing traditions.
Recovery is Culturally Based and Influenced
“Culture and cultural background in all its diverse representations — including values, traditions, and beliefs — are keys in determining a person’s journey and unique pathway to recovery (Dulmus and Nisbett, 2013).”
Your willingness to learn as much as you can about the different cultural identities that are important to the people you serve can help build trusting, authentic relationships. A person’s values, traditions, and beliefs can play a crucial role in their recovery. Essential recovery support often comes from family members, churches, mosques, or temples, and from communities and neighborhoods that embrace recovery. Understanding how to help people in recovery increase their network of support and connect with a community of recovery they identify with are all key elements of peer support.
The National CLAS Standards
Achieving health equity in our lifetimes likely requires adoption of all the National Culturally and Linguistically Appropriate Services Standards (CLAS), which comprise 15 recommended action steps for individuals and health and health care organizations aimed at improving quality and eliminating health disparities. These standards offer a roadmap for achieving health equity, for respecting the whole person and responding to individual needs. But for now, only some of the CLAS Standards are mandatory for any healthcare agency that receives federal funding.
The CLAS Standards 4, 5, 6 & 7 apply to Communication and Language Assistance. They may be mandatory in many settings that hire certified peer support specialists. These Standards also apply to people with disabilities that may need assisted communication devices or services to access care, for example, individuals who are deaf and hard of hearing. Here are the mandatory standards:
| 4 | Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. |
| 5 | Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. |
| 6 | Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. |
| 7 | Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations |
Understanding Legislation
Since many individuals and groups are already dealing with disparities, it is important for peer support specialist to provide information on protected rights of people with substance use and mental health disorders. They include the right to be free from discrimination, the right access care through insurance, and the right to keep treatment records private. Most of these rights are protected by Federal Law, while some state laws provide additional protections.
Federal anti-discrimination laws include the Americans with Disabilities Act, privacy laws such as 42 CFR Part 2 and HIPAA, and the SUD Mental Health Parity & Addiction Equity Act of 2008 (MHPAEA) which applies to health care coverage. The Olmstead US Supreme Court Decision applies to the right of people with “serious mental illness” to receive treatment in the community rather than an institutional setting.
The ADA and Rehab Act
According to the Americans with Disabilities Act (“ADA”) and Rehabilitation Act of 1973 (“Rehab Act”) which is interpreted the same as the ADA, past substance use disorder involving illegal use of drugs is generally considered a “disability.” However, current substance use disorder involving illegal use of drugs is generally not a “disability,” but that does not apply to receipt of health care.
Discriminating against people with mental health and addictive disorders is prohibited under ADA in the following settings:
Employment Settings
- Private employers with 4+ employees, state and local government agencies, and licensing agencies cannot discriminate under the ADA.
State/Local Government Activities
- Public hospitals, benefits, jails, sentencing, probation, nurse/physician licensure, and zoning are included in the state/local government category.
Places of Public Accommodation
- A place of public accommodation refers to a private place open to the public. Examples include schools, camps, health care providers, and insurers.
Housing (FHA)
- Landlords, sellers, and real estate agents/brokers may not discriminate against individuals covered by the ADA when selling or renting FHA housing.
Olmstead Decision
In 1995, the Olmstead case disputed the State of Georgia’s right to keep two women in a mental institution after medical staff said they could be treated in the community. The State did not have a community mental health service system at the time. The case went to the US Supreme Court in 1999. The Court ruled such confinement discriminatory and upheld the right to receive appropriate treatment in the least restrictive setting.
OlmsteadRights.org provides resources and information for self-advocates, family and friends of people with disabilities, and legal advocates alike.
SUD Mental Health Parity & Addiction Equity Act of 2008 (MHPAEA)
The SUD Mental Health Parity & Addiction Equity Act of 2008 (MHPAEA) (the “federal parity law”) requires insurers to provide mental health/substance use disorder (MH/SUD) benefits at parity with medical/surgical benefits. Certain provisions of the Affordable Care Act strengthened these requirements. California Parity Law was limited in scope until it was broadened in 2021. It works in tandem with federal parity law to require coverage for MH/SUD on par with medical/surgical benefits. These laws apply to all public and private insurers with a few exceptions (e.g., Medicare, Tri-Care).
42 CFR Part 2
A very strict privacy law, 42 CFR Part 2, only applies to treatment records for people with substance use disorders at programs that receive federal funds. It was enacted to prevent fear of arrest for deterring people from seeking treatment. Generally, it requires a written, time-limited release that specifies what part of your records to release and to whom. HIPAA law applies to all health records but has fewer privacy protections. HIPPA allows more information to be shared with law enforcement, the legal system, and with other healthcare providers without asking permission.
RESOURCES
Addiction in the African American Community
References
Bernstein J, et al. Perceived discrimination, racial identity, and health behaviors among black primary care patients who use drugs. J Ethn Subst Abuse. 2017.
Nellis, A. (2021, October 13). The Color of Justice Racial and Ethnic Disparity in State Prisons. Retrieved from The Sentencing Project: https://www.sentencingproject.org/publications/color-of-justice-racial-and-ethnic-disparity-in-state-prisons/
Olmstead Rights. (n.d.). Retrieved from https://www.olmsteadrights.org
SAMHSA Center for Behavioral Health Statistics and Quality. Results from the 2017 National Survey on Drug Use and Health: Detailed Tables.