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Official websites use. Share sensitive information only on official, secure websites. Knowledge about the meanings and consequences of behaviors associated with drug use among diverse populations is essential for developing effective public health and clinical strategies. Key differences were identified in drug of choice, in all of the ASI domains except medical, in validity of self-report of use, and in rate of treatment contact. Differences related to race and ethnicity should be evaluated to determine needs for a variety of substance abuse treatment modalities, assure timely access to culturally competent care, and develop policies that are tailored to real conditions. Although differences in pattern of use have been identified for specific demographic characteristics, current levels of knowledge about the functional meaning of these differences and their affect on access to treatment is insufficient for effective program and policy development. This report describes racial and ethnic differences in standard measures of addiction and contact with the substance abuse treatment system among heroin and cocaine using patients encountered in the Urgent Care Clinic at an inner city hospital. This data set was developed by surveying 23, clinic patients — as part of a randomized, controlled trial of a peer-led, motivational intervention to reduce drug use and associated health consequences, reported separately. Following enrollment, but prior to randomization, an outreach worker functioning as a research assistant administered the Addiction Severity Index or ASI, a measure of distress in seven domains: medical, legal, employment, drug, alcohol, family and psychological functioning scored from 0. The intervention group received a semi-scripted brief motivational interview tailored to individual behavior, risks, culture, and language, along with referrals if desired, and a telephone booster in ten days. This brief 30 minute interaction, designed to assist patients to recognize and change behaviors that pose significant health risks, was first adapted in , with assistance from Dr. Stephen Rollnick, for Emergency Department use. The control group, in contrast, received only the written handout containing advice and referral numbers. The peer research associates tracked no-shows using the hospital clinic appointment system, and visited shelters and known sites for drug users. They collected self report data at 3 and 6 months, and administered a questionnaire to ascertain treatment contact and successes in trying to quit or cut back on heroin and cocaine use. In addition, hair samples were collected at the six month follow-up visit. Double entry and other quality control measures were established to monitor data status. At six months post-enrollment, we measured the percentage of participants with 30 days of abstinence from both cocaine and opiates, from opiates only, and from cocaine only, by self-report and by hair testing, limiting the analysis to those participants with positive hair tests at enrollment who returned for follow-up at six months. For reductions in the amount of drug present in hair as evidenced by chemical analysis, we compared changes in levels of cocaine from baseline to 6 months and conducted a similar analysis of opiate levels. The amount of hair collected provided a thirty day window for use. We used SAS version 8. Odds ratios for the effect of race and primary language on ASI scores and on treatment contact were calculated using logistic regression. For each of these analyses a core model was stipulated, consisting of variables for gender, race, age, Euroquol health status scores, dual diagnosis, and randomization status. Variables measuring educational level, drug route and drug problem severity DAST score at baseline, polydrug use, injection drug use, baseline ASI drug score, number of previous treatment episodes were then added in sequentially to identify potential confounders. The Blacks were older than the Hispanic or White enrollees with a mean age of Black males were more likely to report living in private homes, less likely to live in shelters and more likely to be employed full or part-time than Hispanics or Whites. A higher percentage of Hispanics were born outside the continental U. The mean age was lowest for Hispanics at Among enrolled in the study who self identified as White, They had a higher rate than Hispanics of living in private homes and working full or part time, but a lower rate than the Black enrollees. The distribution in hair revealed a similar pattern. Hispanics also reported a lower rate of alcohol use than Blacks or Whites. Chemical markers confirmed heroin as the drug of choice for Hispanics. Whites had higher rates of heroin use but lower rates of cocaine use than Blacks, and lower rates of alcohol use in last month than Blacks but higher rates than Hispanics. The ASI measures degree of difficulty in functioning in seven domains on a scale of 0—1. There were no significant differences between racial and ethnic groups on the medical scale despite relatively high levels of distress for all groups 0. All three groups also reported high degrees of distress on the employment scale with scores of 0. Baseline ASI scores for our study group were higher for medical, legal, and psychiatric distress than ASI sub-scale scores reported in a larger sample of 8, Boston residents who were seeking treatment through three Central Intake Units. Blacks were significantly lower on the drug and psychological scales, and scored 0. Hispanics scored significantly higher than Blacks and Whites on the employment scale with a score of 0. Whites scored significantly higher than Blacks on the psychological scale 0. After adjustment for demographic and substance use variables in multivariate analysis, race was a predictor of discordance at follow-up. For the group as a whole, the intervention arm resulted in a higher rate of abstinence from cocaine, from opiates and from both drugs compared to controls OR 1. In multivariate analysis, younger age, white and Hispanic race, and the intervention all predicted abstinence from 1 all drugs and 2 from cocaine only. Hispanics and Whites were four times more likely than Blacks to be abstinent from cocaine and three times more likely to be abstinent from any drug. Race was not a significant predictor for abstinence from opiates based on biochemical analysis. Enrollees were interviewed at a 6-month follow-up visit and questioned about their drug treatment contact. They were asked specifically about their experiences with short stay detox, outpatient counseling, methadone clinic, residential programs and AA and NA. There were significant differences in self report of treatment contact among racial and ethnic groups see Table 3. These results were confirmed by data from the Massachusetts State MIS Treatment Database, which contains information furnished to the state by treatment facilities required for service reimbursement. In the State Treatment facility report, In the state database, Hispanics had higher attendance at short-stay detox than Blacks RR 2. In the state database, Whites had a higher rate than Blacks of documented contact with all modalities and higher rates than Hispanics except for detox. There were no differences in utilization among White cocaine-only users and the other groups. Many enrollees in this study reported high levels of social deprivation unemployment, homelessness, limited education and poor physical and mental health , and registered high levels of distress on the ASI, but Hispanics appeared to experience the lowest levels of education and the highest rate of unemployment and homelessness. Whites had higher levels of education, employment and living in private residences than Hispanics, yet White enrollees faired worse than the Blacks and Hispanics in a number of areas such as feeling threatened or afraid, injured in the last year, having nothing to look forward to and exhibited more severe psychological distress on the ASI. They also trended toward greater family and legal distress. There were clear racial and ethnic differences between Blacks, Hispanics and Whites in drug of choice, with Blacks more likely to be users of cocaine than Hispanics or Whites, while Whites were more likely to be current users of heroin than Hispanics or Blacks. Whites had significantly higher scores than Blacks on the ASI drug and psychiatric composite scores, and a trend toward higher scores on the legal and family domains. Blacks had higher scores on the alcohol composite score. High levels of employment troubles were noted for all groups, but Hispanics had greater employment difficulties and higher drug severity scores than Whites. Among Hispanics, there was a trend toward higher drug and psychiatric scores than for Blacks. Sensitivity of self-report at follow-up was diminished for all groups. There were no racial or ethnic differences in rates of discordance found at baseline, but at the 6 month follow-up, among heroin users who tested positive for both substances at baseline, Hispanics were less likely to disclose cocaine use than Whites, after adjustment for other demographic and substance use variables. Patients who were followed were older, more likely to be insured and Black, more likely to have dual diagnosis, more likely to report the use of cocaine only. However among those followed, there were no significant differences based on randomization. Of the enrollees, had hair samples or sufficient quantities of hair for testing at both data points. The OR for the randomization effect remained stable in the regression for each variable in the model, and was not changed by the race variable. However in multivariate analysis, race was a predictor of abstinence independent of randomization status. Whites and Hispanics were four times more likely than Blacks to be abstinent from cocaine and three times more likely than Blacks to be abstinent from any drug. Race was not a predictor, however, for opiate abstinence. Racial and ethnic differences were found on both self report and objective data for treatment contact from the Massachusetts Bureau of Substance Abuse Service At six-month follow-up, fewer Blacks reported that they went to a detox program compared to Hispanics or Whites. The State Treatment Data confirm that significantly fewer Blacks attended short stay detox programs compared to Hispanics and Whites. Whites were more likely than Blacks to attend other treatment modalities as well -- outpatient, methadone, residential recovery homes, and Hispanics had higher rates of methadone contacts than Blacks. Subgroup analysis showed that there were no differences by race or ethnicity among cocaine-only users, but among poly drug users, who, unlike cocaine users, were eligible for entry to detox, Whites and Hispanics had greater contact with detox programs than Blacks. Because this study provided so much rich material for interpretation, we present a table of the principle conclusions to assist in discussion of results see Table 5. In , we reported heroin and cocaine related visits. Whites had more frequent heroin visits than Hispanics and Blacks, while Blacks had more frequent cocaine related ED visits than Whites and Hispanics. These racial and ethnic patterns of drug use for our hospital clinics and ED patients are supported by other studies. In a ten year study of cocaine and opiate overdose deaths New York City, cocaine was more commonly found in black decedents, and opiates and alcohol in Hispanics and White fatalities. Other studies have looked at racial differences in ASI scores. The authors controlled for differences in gender, age, income and treatment site. There were no significant differences between racial groups for medical severity scores in either study see Table 6. In our study, use of drugs appears to create commonality in a high level of distress across the seven ASI domains. However the pattern of greatest dysfunction differed by race, with Hispanics experiencing the highest level of problems in employment and legal issues, and Whites reporting the highest level of family and psychological effects. In the multivariate analysis of data at follow-up, Hispanics were least likely to have concordance between self-report and biochemical results. It is possible that discordance reflected a desire to please the interviewers, who were recognized Black and Hispanic members of their peer group who were in recovery. Also cocaine use may carry more of a stigma and legal consequence among heroin users, or represent a perceived barrier to those seeking methadone treatment. Discordance may represent failure to disclose either deliberate concealment or denial , or it might possibly reflect external contamination or racial differences in hair biology. Furthermore, the cocaine levels in our study samples were much higher among those who failed to report cocaine use than the levels that are usually found to be associated with either external contamination or passive exposure. There have been concerns that differences in hair biology across racial and ethnic groups may contribute to discordance, because drugs may bind preferentially to hair containing higher levels of melanin. There is disagreement among researchers as to the effects of differences in race as well as age and gender on biochemical hair test results. Hair analysis may also be altered by treatments such as chemical relaxants and colorants, which may increase porosity of hair and allow more drug to be absorbed. Our finding that race and ethnicity were not significant predictors of disclosure at baseline supports the reliability of the RIA hair analysis, despite variations in hair structure, treatments and melanin content among populations. Several possible explanations can be advanced for the racial and ethnic differences we identified in abstinence at six months post enrollment. Whites and Hispanics, who had higher rates of abstinence from cocaine, were more likely to be primarily heroin users at baseline. They used less cocaine, and may therefore have found it easier to quit using cocaine. White and Hispanic polydrug users may also have had more opportunities to address their cocaine use while they were in treatment for their primary drug, heroin. Blacks, who were more likely to be cocaine only users, may have had less access to treatment modalities to address their primary drug. This data confirms the demand for treatment, and makes the racial differences in treatment admission that were identified in this study especially disturbing. It is clear that very few of our enrollees obtained such specialized and costly services. Utilization of these treatment modalities was lower among Hispanics than Whites but higher than for Black enrollees. Access issues rising from inability to pay do not seem to explain these differences. In the Boston area during the time of the study there were few barriers to detox admissions based on insurance status or ability to pay. Polydrug cocaine users could be admitted for their heroin or alcohol use, and patients with cocaine and psychiatric illness could be placed in dual diagnosis programs if they were insured. Many patients knew that they could report suicidality to increase their chances of successful placement. Given this level of access, why were Black so underrepresented in the treatment system? In our sample, Blacks primarily used cocaine, and Whites and Hispanics used heroin more frequently than Blacks. We looked at data for cocaine-only users and found no differences between Blacks, Hispanics and Whites in short-stay detox admissions, but rates of contact were low for all groups. This finding would suggest that the reduced rate of contact with the treatment system among Blacks is not limited to factors related to cocaine use. Data from this study do not permit us to establish conclusively whether the race-based difference identified in admission to detox represents a difference in perceived need or a disparity in meeting that need. We often hear patients voice concerns about losing their homes, their mail, checks and property if they were to enter a detox. Further study would be needed to explore this potential reason for under-utilization of detox. It may also mean that Blacks are appropriately utilizing detox facilities, and the others would benefit from safe housing or other modalities of care. Certainly outpatient services are badly needed, especially for cocaine users. Cognitive behavioral therapy and motivational enhancement, which have been effective with alcohol abuse and dependency, are only beginning to be implemented for cocaine users in the public outpatient setting. There is an obvious need for more trained interventionists who can deliver these services in a way that is acceptable and useful to racial and ethnic minorities. The current detox system in Massachusetts and particularly the Boston areas has recently experienced radical cutbacks in Medicaid benefits. These cutbacks have increased admissions to our hospital, increased the length of the ED stay, and contribute to ED and hospital overcrowding. One client in this study, who had insurance, waited eight hours while peer educators worked their way through layer after layer of insurance company gatekeepers until he finally found an individual who could be convinced of the potential cost-savings from treatment; it then took many more calls to find a facility that was able to accept this patient. Those with no insurance who were highly motivated for treatment often waited days on a list for placement, returning each morning for news; some succeeded in making contact, but many others returned to the streets. Many cocaine and heroin users come to the health system seeking help for their addiction and are open to negotiating changes in their drug use. The brief motivational intervention tested in this study was highly successful for Hispanics and Whites, and assisted a large number of Blacks to achieve abstinence. However stereotypes and biases may prevent some patients from receiving the care that they need. No health care provider had inquired about drug use, least of all injection drug use, perhaps because her appearance, age and race did not fit an expected pattern—until she turned up HIV positive. We attribute the success of the intervention to the atmosphere of respect established by the African American and Hispanic outreach workers who provided the intervention. These responses did not differ by race. Several questions raised here deserve further investigation, principally the interpretation and consequences of reduced intervention effectiveness and reduced treatment contact among Blacks. In particular, we need to improve our understanding of the impact of racial and ethnic differences in order to devise effective strategies tailored to assisting Black and Hispanic populations to achieve abstinence from drugs. As a library, NLM provides access to scientific literature. J Addict Dis. Published in final edited form as: J Addict Dis. Find articles by Edward Bernstein. Find articles by Judith Bernstein. Find articles by Katherine Tassiopoulos. Find articles by Anne Valentine. Find articles by Timothy Heeren. Find articles by Suzette Levenson. Find articles by Ralph Hingson. PMC Copyright notice. The publisher's version of this article is available at J Addict Dis. Open in a new tab. Study results are generalizeable to urban areas. Drug of Choice African Americans were more likely to use cocaine, and Hispanics and Whites more likely to use heroin. Drug of choice differs by race, and that difference may confound access to treatment. ASI scores High levels of distress were found on all subscales across racial and ethnic differences. Scores were highest for Hispanics in the employment and legal subscales, and for Whites on the family and psychologic subscales Use of drugs creates a degree of commonality in ASI scores, but distress and loss associated with drug use vary with race and ethnicity. Self-report of continued drug use may have been influenced by social desirability. Intervention success Brief motivational intervention was most successful with Hispanics and Whites. Intervention may have been less successful with Blacks because of factors related to cocaine use, which was the drug of choice for Blacks in this study. Treatment system contacts Although readiness to enter treatment did not differ by race, Blacks were least likely to report contact with any treatment modality. Racial differences in treatment admission may be influenced by lack of detox facilities for cocaine, the drug of choice for Blacks, and lack of methadone treatment, since opiates are the drug of choice for Hispanics. However language and insurance barriers may present a significant barrier for Hispanics, and Blacks who were polydrug users still had a lower rate of contact, suggesting the possibility of bias in admissions. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Hispanics reported the lowest educational levels and highest rates of unemployment and homelessness. African Americans were more likely to use cocaine, and Hispanics and Whites more likely to use heroin. High levels of distress were found on all subscales across racial and ethnic differences. Scores were highest for Hispanics in the employment and legal subscales, and for Whites on the family and psychologic subscales. Use of drugs creates a degree of commonality in ASI scores, but distress and loss associated with drug use vary with race and ethnicity. Brief motivational intervention was most successful with Hispanics and Whites. Although readiness to enter treatment did not differ by race, Blacks were least likely to report contact with any treatment modality.

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