American Society of Addiciton Medicine
Jul 29, 2022 Reporting from Rockville, MD
Advancing Racial Justice in Health Care through Addiction Medicine
https://www.asam.org/advocacy/public-policy-statements/details/public-policy-statements/2022/07/29/public-policy-statement-on-advancing-racial-justice-in-health-care-through-addiction-medicine
Jul 29, 2022
ASAM’s Public Policy Statement on Advancing Racial Justice in Health Care through Addiction Medicine is the second statement of ASAM’s policy series on racial justice. This second statement focuses on actions that healthcare professionals, healthcare systems, institutions, and organizations, professional medical entities, researchers, and health professional educators can take to help advance addiction medicine and its role in addressing health disparities for people of color.

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American Society of Addictin Medicine

Public Policy Statements

Advancing Racial Justice in Health Care through Addiction Medicine

 

Purpose

This is the second in a three-part series of public policies on racial justice through which ASAM summarizes the evidence that systemic racism is a major social determinant of health1 with profound, deleterious effects on the lives and health of Black, American Indian/Alaska Native, Hispanic/Latinx, Asian, Pacific Islander, and other racially and ethnically minoritized[*] and disenfranchised people (hereinafter collectively referred to as Black, Indigenous, People of Color (BIPOC)).2,3 This series of policy statements is part of ASAM’s effort to recognize, understand, and then counteract the adverse effects of America’s pervasive, historical, yet continuing, systemic racism, specifically with respect to full-spectrum addiction care, including prevention, early intervention, harm reduction, diagnosis, treatment, and recovery.

The series’ first policy statement4 focuses on actions that addiction medicine professionals should take to tackle systemic causes of health disparities. It recognizes that many choices made by healthcare professionals, while not always the result of conscious or intentional racism, may nonetheless reflect biases that operate in the context of longstanding systems and policies that marginalize and exclude BIPOC.5 The corrective response must consist of conscious efforts to overcome these biases and unjust systems.

This second policy statement focuses on actions that healthcare professionals, healthcare systems, institutions, and organizations, professional medical entities, researchers, and health professional educators can take to help advance addiction medicine and its role in addressing health disparities for BIPOC. It highlights the longstanding role of the criminal legal system and child welfare in inappropriately assuming responsibility for, or otherwise interfering upon, clinical decisions for people with substance use disorders (SUD), with the most adverse consequences disproportionately affecting BIPOC. Finally, it highlights the need for clinicians and patients to take responsibility for shared decision making with respect to full-spectrum addiction care.

By illustrating how punitive responses have failed BIPOC who use substances, ASAM intends to demonstrate the urgent need for policy reforms that prioritize full-spectrum addiction care over punishment, reduction of stigma against all people who use substances, and enhancement of the health and well-being of all people who have the disease of addiction.

Background

As detailed below, BIPOC with SUD often do not receive evidence-based addiction care and are more likely than White people to be treated punitively by the criminal legal and child welfare systems as a result of substance use.6 To rectify this situation, groundbreaking change will be required within the criminal legal and child welfare systems, in addition to major reforms within healthcare systems, institutions, and organizations, professional medical entities, health professional education, and medical research and practices.

Substandard care for BIPOC who use substances

There is ample evidence of systemic racism within the U.S. healthcare system. In 2002, the Institute of Medicine concluded that “racial and ethnic minorities receive lower-quality health care than white people—even when insurance status, income, age, and severity of conditions are comparable.”7 Health care still has far to go to address these inequities. For example, a study published in 2022 found that Black patients were 2.5 times as likely as White patients to have a negative descriptor (such as ‘resistant’ or ‘noncompliant’) included in their health record.8

The situation for BIPOC is equally bleak in addiction medicine, where BIPOC are less likely than White people to receive the standard of care in a range of areas. Examples include:

  • Black patients are less likely to receive medication for alcohol use disorder.9
  • BIPOC are less likely to be offered the standard of care—particularly buprenorphine—to treat opioid use disorder (OUD).10–14
  • BIPOC are less likely to complete addiction treatment at least partly due to inequities in social determinants of health (SDoH) caused by structural racism, specifically, financial and housing instability.15
  • BIPOC face more barriers than White individuals do in accessing harm reduction services.16–19

    Changes in the current situation—including the adoption of an explicitly antiracist20 approach, and the development of more equitable institutions and social conditions—are needed to address these and other problems faced by BIPOC who use substances.21

Use of punitive systems against BIPOC who use substances

Overall, the United States’ use of punitive systems to address illicit substance use and SUD has been ineffective in addressing the nation’s overdose crisis, and larger policy changes—including an examination of appropriate penalties for personal drug use possession—are needed to reverse this approach. The impact of this failed approach has been felt most acutely by BIPOC. 

A historically racialized, punitive approach to substance use in the United States has been weaponized against BIPOC, including the use of opium laws against Asian people, cannabis policy against Latinx people, and disparate cocaine sentencing laws against Black people.4   In addition, methadone treatment for OUD was authorized during a time of racialized “anti-crime politics,” which resulted in a highly-regulated, closed clinic system that emphasized regulatory compliance more than treatment access.22,23 Highly-detailed federal regulations that surround this specific medical practice have oriented it  away from primary care24 to the detriment of individualized patient care,  and have contributed to racial health disparities among people with OUD.25,26 Indeed, today’s racially-patterned access to methadone and buprenorphine for OUD denies Black and Hispanic/Latinx communities equitable access to buprenorphine, which is a more flexible form of care.27 Finally, perhaps one of the most compelling data points is that although Black and White Americans sell and use drugs at similar rates, Black people in the United States are 2.7 times as likely to be arrested for drug-related offenses and 6.5 times as likely as White people to be incarcerated for drug-related crimes.28,29

In general, the criminal legal system has done a poor job providing evidence-based care to people with SUD.6 Fewer than 5% of people referred by the criminal legal system to specialty treatment programs for the treatment of OUD received standard of care medication.30 In addition, very few carceral facilities offer medications for OUD, especially methadone or buprenorphine; people already treated with these medications are often forced to stop this life-saving therapy, suffer withdrawal, and risk overdose and overdose death. Disturbingly, this is happening against a backdrop of research indicating that individuals who are incarcerated are 129 times more likely to die from overdose within the first two weeks after release when compared to the general U.S. population – particularly from opioids.31 Given the disproportionate involvement with the criminal legal system, this low standard of care poses a particular risk for BIPOC.

Healthcare professionals have participated in providing substandard care within the criminal legal system by ceding control over the treatment plans to criminal legal system authorities who are not clinicians. For example, the criminal legal system has been shown to: exclude the use of methadone or buprenorphine as treatment for persons under community correctional control, or impose limits on their use;32 mandate treatment from a limited pool of addiction treatment providers with whom the system contracts, regardless of the individualized needs or third-party insurance coverage of the incarcerated person;33 and refuse to provide methadone or buprenorphine while a person is incarcerated.34 Further, the National Drug Court Institute has found that “representation of African-American and Hispanic individuals in jails and prisons was nearly twice that of both drug courts and probation, and was also substantially higher among all arrestees for drug-related offenses.”35

Research has found, in addition, that clinicians are more likely to order drug tests for BIPOC,36,37 and positive drug test results can lead to negative consequences unrelated to health for BIPOC if disclosed by healthcare professionals to entities outside of health care.

Racial inequities in child protective services response to pregnant and parenting people

Parental substance use is a frequent cause of referrals to child welfare, especially during pregnancy and during or following childbirth. More than one-third of out-of-home placements noted parental substance use as a contributing factor.38 As currently structured, however, healthcare providers often employ a faulty, underlying assumption that substance use in itself is “reportable” even when the “substance” is opioid agonist treatment for OUD (methadone or buprenorphine).39 Most reports to child welfare occur for infants in the first year of life and originate from healthcare professionals.40 Methods of screening41 have historically relied on urine drug testing,42 and healthcare professionals often perceive reporting results as mandatory.43 The practice of “test and report” has been decried as medically unethical and public health ineffective by the American College of Obstetricians and Gynecologists (ACOG), “The laws, regulations, and policies that require health care practitioners and human service workers to respond to substance use and substance use disorder in a primarily punitive way, require health care providers to function as agents of law enforcement.”44 In addition, child welfare reporting undermines patient trust, can discourage a pregnant person from seeking care for OUD for fear of child welfare involvement, contributes to provider moral injury, and worsens racial inequities. There are marked racial inequities in the child welfare response,45 from drug testing, to child welfare reporting, to foster placement, and to the termination of parental rights.39,46 Though Black children are 14% of the children in the United States, they represent 23% of children in foster care and are less likely to be reunified with their families.47 Despite documented evidence that Black and White people have comparable rates of substance use, reports reveal that more Black than White infants have been reported to child welfare due to parental substance use.41

Antiracism efforts needed elsewhere within health care

Just as the criminal legal and child welfare systems have had disproportionately damaging effects on BIPOC, so have many of the structures built and operated by healthcare professionals and administrators. Reforms are needed within healthcare systems, health professional schools, clinical research, and healthcare practice to address and eliminate health inequities.

The effects of SDoH on patient outcomes—particular among BIPOC—have been well-documented.48 Unfortunately, many clinicians and healthcare systems are unprepared to screen for SDoH among their patients and then take action based on the screening results due to inadequate resources.49 In many cases, community-based organizations may be logical partners to work with healthcare institutions.50

Reforms are needed throughout the clinical research enterprise to eliminate disparities. The construct of race is often applied inappropriately in clinical research; existing standards outline how researchers and journals should address this problem.51 Additionally, BIPOC are underrepresented in clinical trials, yielding interventions that may not be culturally appropriate.52 Finally, other research has demonstrated that BIPOC researchers are less likely to receive National Institutes of Health funding than White researchers.53,54 

Other scholarship has highlighted the inappropriate use of race in clinical algorithms put forward by clinical societies and healthcare systems used to make clinical care decisions. Not only may this unnecessarily inject issues of race in clinical care, but the inclusion of race in algorithms may direct additional resources to White patients and away from BIPOC. One recent review found examples of this occurring in clinical fields ranging from cardiology to nephrology to obstetrics.55 

The first document in this series proposed that addiction medicine providers should use trauma-informed care to help BIPOC overcome the trauma associated with racism and criminal legal system involvement. The principles and practice of trauma-informed care—a strengths-based care delivery approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives56,57  –can promote a culture of safety, empowerment, and healing.58–60 This approach is relevant for all healthcare professionals.

Increasing the diversity of the medical workforce, including across addiction medicine programs and practices, can also help improve patient care, satisfaction, and outcomes and alleviate health disparities.61–65 According to the most recent data, less than 12% of physicians self-identified as Hispanic or Black, despite those two groups making up over 30% of the United States population. Trends among medical students show minimal, if any, improvements in medical school diversity.66 Latinx-identified individuals comprise 5.5% of medical school faculty, Black or African American individuals comprise 3.6%, and American Indian or Alaska Native individuals comprise 0.2% of medical school faculty.67 

Recommendations

           Recommendations for reducing criminal legal system influence on addiction care: 

  1. Healthcare professionals should support the elimination of policies that restrict the use of evidence-based addiction treatment for people with SUD who are in carceral settings or under community correctional control. In particular, decisions which involve treatment plans—including the type, duration, choice of medication, and level of care—should be made by healthcare professionals rather than non-clinical authorities in criminal legal systems and should be consistent with standards of care. Given the disproportional involvement of BIPOC with criminal legal systems, such changes are critical to address inequities and help BIPOC receive evidence-based addiction care.

     

  2. Healthcare professionals should support equitable practices in drug courts. Consistent with ASAM policy,32 reforms to drug courts should provide individuals with equitable access to evidence-based treatment for SUD, including all FDA-approved addiction medications available in the community or via telehealth, and prohibit interference of non-clinicians with the clinician-patient relationship. Drug court reforms must address inequities within the drug court system.

     

  3. Healthcare professionals should support legislative and regulatory changes to enhance harm reduction efforts, including overdose prevention sites, syringe service programs, exploring other medications for SUD, and drug checking services. Healthcare professionals should be able to refer people who use substances for evidence-based, harm reduction interventions or use those interventions as a standard part of patient care. Healthcare professionals should support equitable access to all evidence-based harm reduction services for people who need them, with a specific effort to increase the engagement of BIPOC communities in the development of such services.  

     

  4. Healthcare professionals should use caution in ordering drug tests (toxicology) and sharing clinical drug testing (toxicology) results with entities outside of health care, including those in the criminal legal and child welfare systems. The goals of healthcare and criminal legal and child welfare systems do not always align. Healthcare professionals should educate patients on confidentiality and the purpose of the external request and obtain informed consent before making any disclosures.68

     

     Recommendation for reducing child welfare system influence on addiction care

  5. Healthcare professionals should support the removal of legal mandates and local practice standards to report pregnant or parenting people to child protective services or other government agencies on the sole basis of substance use or SUD. Such requirements can be harmful and discourage people from seeking addiction treatment and prenatal care, which can lead to worse health outcomes for pregnant person, parent, and infant.

    Recommendations for healthcare systems, institutions, and organizations, professional medical entities, and researchers

  6. Efforts to increase diversity within the healthcare workforce are critical to improving addiction care. Organizations and institutions within healthcare systems must act with the understanding that there are structural implications to fostering a sense a belonging69 for BIPOC patients who use substances and prioritize garnering points of view from a diverse group, not a select few.69 To improve addiction care and research, healthcare systems must hire and compensate individuals from the communities that they serve. These systems demonstrate the value of diversity when they listen to and implement recommendations from diverse sources and mentor and promote diverse individuals to leadership positions within the system.

     

  7. Healthcare systems should expand the range of evidence-based services they provide in order to meet the needs of BIPOC with SUD, including the initiation of medication for OUD (e.g. buprenorphine) and offering naloxone for overdose reversal in emergency departments, hospitals, other urgent care settings, and primary care settings. Under certain circumstances, failure to do so may be a violation of federal law, including the Civil Rights Act.70

     

  8. All healthcare settings should consider and address social determinants of health—including housing, education, transportation, employment, and racism itself—as part of a patient’s comprehensive treatment and recovery. Providers should consider open access scheduling, mobile services, community-based sites, and expansion of telehealth or other remote service deliveries, and working with local community-based organizations71 to help address those needs.

     

  9. All healthcare settings—along with other professional medical entities—should assess their care systems, clinical guidelines and algorithms,72 and policies through a health equity and racial justice lens and revise them as needed. For example, new care approaches, such as telemedicine, may unintentionally propagate inequities if not implemented appropriately.73,74

     

  10. In medical journals, racism must be interrogated as a critical driver of racial health disparities in addiction medicine,51 ensuring that clinical research related to addiction is reformed to be antiracist. BIPOC with lived experience should be better represented as part of clinical trials, including as part of the team conceptualizing, conducting, analyzing and interpreting, and disseminating the clinical research.52,75 Research thus conducted can be applied to the explicit end goal of translating the findings into improved clinical practice for BIPOC who use substances. Efforts focused on community engagement, recruitment, and retention of a diverse pool of research participants is imperative to achieve this goal.69

     

  11. In addition to implementing needed changes to address healthcare inequities and ensure that BIPOC have equal access to evidence-based addiction care, healthcare institutions should regularly assess whether their antiracist policy interventions are having their desired effect. Healthcare systems should involve BIPOC staff, BIPOC members of communities, particularly those BIPOC with lived experience, and BIPOC researchers as part of this process.69

     

    Recommendations for healthcare professionals and their medical practices

  12. Healthcare professionals should advocate for substance use to be addressed as a health issue, and addiction as a treatable, chronic medical disease and not be addressed by the criminal legal system with arrest and incarceration. The criminal legal system should not be used to interfere with, or influence, the assessment, diagnosis, or treatment decisions of those with SUD. Too often, these clinical decisions have been relinquished by healthcare professionals to the criminal legal system. Given that the criminal legal system has had inequitably detrimental effects on BIPOC, reforms within this system are particularly needed to achieve racial justice.

     

  13. Healthcare professionals should regularly examine their practices and whether they deliver health care services in a biased way. When biases are identified, action should be taken to counter biased practices in order to deliver equitable, compassionate and anti-racism-informed4 addiction care to all people who need it.

     

  14. Healthcare professionals must lead medical practices that acknowledge and respond to experiences of racism of BIPOC patients who use substances by (a) trusting and respecting those patients’ experiences through trauma-informed care, (b) assessing those patients for social determinants of health, including those that are linked to racism, and connecting them with community resources, and (c) evaluating their medical practices based on staff diversity and inclusion as well as patient satisfaction and retention in treatment among their BIPOC patients with SUD.

     

  15. Healthcare professionals should develop proficiency4 in, practice, and demonstrate leadership in trauma-informed care for BIPOC patients who use substances as well as structural competency[†], so that they can (a) understand those patient experiences in the context of structural factors that influence their health; (b) intervene to address those structural factors, such as inequalities in law enforcement, housing, education, access to health care, and other resources, that put patients at risk for unhealthy substance use and addiction or limit their access to addiction prevention, treatment and recovery supports; and (c) collaborate with community leaders with humility.4,76

     

  16. Preventing, screening for, assessing and intervening regarding SUD should be considered an essential part of general medical practice. In working with BIPOC who use substances, this includes healthcare professionals having the skills and training to prescribe a range of treatment approaches, including addiction medications.

     

    Recommendations for healthcare professional education and training

  17. Providers of training in medical school, residency, fellowship and continuing medical education (CME) programs should review their curricula to identify gaps related to addiction care, trauma-informed care, structural competency, and racial understanding. Clinical educators should develop and promote addiction medicine training courses grounded in trauma-informed care and structural competency to improve the outcomes of patients who are socially marginalized by virtue of their race, e.g., those who are identified by the criminal legal system due to disparate policing and then are referred or mandated to addiction treatment. Education and training of healthcare professionals on addiction care should be evaluated to ensure content aligns with the principles of cultural sensitivity and inclusion, health equity, and racial justice.

     

  18. Healthcare professionals should advocate for creation and implementation of policies that lead to a more diverse clinical workforce equipped to treat SUD69 and should seek opportunities to mentor BIPOC physicians and other clinicians. The outcomes of these policies should be regularly assessed to ensure that they are achieving their stated goals. Robust funding should be made available and targeted for scholarships and loan repayment for BIPOC healthcare professionals who treat SUD.

    Adopted by the ASAM Board of Directors July 28, 2022.

        © Copyright 2022. American Society of Addiction Medicine, Inc. All rights reserved. Permission to make digital or hard copies of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for commercial, advertising or promotional purposes, and that copies bear this notice and the full citation on the first page. Republication, systematic reproduction, posting in electronic form on servers, redistribution to lists, or other uses of this material require prior specific written permission or license from the Society. ASAM Public Policy Statements normally may be referenced in their entirety only without editing or paraphrasing, and with proper attribution to the society. Excerpting any statement for any purpose requires specific written permission from the Society. Public Policy statements of ASAM are revised on a regular basis; therefore, those wishing to utilize this document must ensure that it is the most current position of ASAM on the topic addressed.

     

     

     

    1. Paradies Y, Ben J, Denson N, et al. Racism as a Determinant of Health: A Systematic Review and Meta-Analysis. PLOS ONE. 2015;10(9):e0138511. doi:10.1371/journal.pone.0138511
    2. Gunaratnam Y. Researching Race and Ethnicity: Methods, Knowledge, and Power. Sage Publications; 2003.
    3. Sotto-Santiago S. Time to Reconsider the Word Minority in Academic Medicine. J Best Pract Health Prof Divers. 2019;12(1):72-78.
    4. American Society for Addiction Medicine. Advancing Racial Justice in Addiction Medicine. Default. Published February 25, 2021. Accessed March 2, 2022. https://www.asam.org/advocacy/public-policy-statements/details/public-policy-statements/2021/02/25/public-policy-statement-on-advancing-racial-justice-in-addiction-medicine
    5. Braveman PA, Arkin E, Proctor D, Kauh T, Holm N. Systemic And Structural Racism: Definitions, Examples, Health Damages, And Approaches To Dismantling. Health Aff (Millwood). 2022;41(2):171-178. doi:10.1377/hlthaff.2021.01394
    6. American Society for Addiction Medicine. Treatment of Opioid Use Disorder in Correctional Settings. Default. Published August 15, 2020. Accessed March 11, 2022. https://atest.asam.org/advocacy/public-policy-statements/details/public-policy-statements/2021/08/09/asam-public-policy-statement-on-treatment-of-opioid-use-disorder-in-correctional-settings
    7. Minorities More Likely to Receive Lower-Quality Health Care, Regardless of Income and Insurance Coverage | National Academies. Accessed March 2, 2022. https://www.nationalacademies.org/news/2002/03/minorities-more-likely-to-receive-lower-quality-health-care-regardless-of-income-and-insurance-coverage
    8. Sun M, Oliwa T, Peek ME, Tung EL. Negative Patient Descriptors: Documenting Racial Bias In The Electronic Health Record. Health Aff (Millwood). 2022;41(2):203-211. doi:10.1377/hlthaff.2021.01423
    9. Williams EC, Gupta S, Rubinsky AD, et al. Variation in receipt of pharmacotherapy for alcohol use disorders across racial/ethnic groups: A national study in the U.S. Veterans Health Administration. Drug Alcohol Depend. 2017;178:527-533. doi:10.1016/j.drugalcdep.2017.06.011
    10. Anderson KE, Saloner B, Eckstein J, et al. Quality of Buprenorphine Care for Insured Adults With Opioid Use Disorder. Med Care. 2021;59(5):393-401. doi:10.1097/MLR.0000000000001530
    11. Khatri UG, Pizzicato LN, Viner K, et al. Racial/Ethnic Disparities in Unintentional Fatal and Nonfatal Emergency Medical Services–Attended Opioid Overdoses During the COVID-19 Pandemic in Philadelphia. JAMA Netw Open. 2021;4(1):e2034878. doi:10.1001/jamanetworkopen.2020.34878
    12. Lagisetty PA, Ross R, Bohnert A, Clay M, Maust DT. Buprenorphine Treatment Divide by Race/Ethnicity and Payment. JAMA Psychiatry. 2019;76(9):979-981. doi:10.1001/jamapsychiatry.2019.0876
    13. Newsome M, December 17 NCHN, 2021. Treatment for opioid use disorder – not separate but still unequal. North Carolina Health News. Published December 17, 2021. Accessed March 2, 2022. http://www.northcarolinahealthnews.org/2021/12/17/treatment-for-opioid-use-disorder-not-separate-but-still-unequal/
    14. Nguyen T, Ziedan E, Simon K, et al. Racial and Ethnic Disparities in Buprenorphine and Extended-Release Naltrexone Filled Prescriptions During the COVID-19 Pandemic. JAMA Netw Open. 2022;5(6):e2214765. doi:10.1001/jamanetworkopen.2022.14765
    15. 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 Serv Res. 2013;48(4):1450-1467. doi:10.1111/1475-6773.12031
    16. Rosales R, Janssen T, Yermash J, et al. Persons from racial and ethnic minority groups receiving medication for opioid use disorder experienced increased difficulty accessing harm reduction services during COVID-19. J Subst Abuse Treat. 2022;132:108648. doi:10.1016/j.jsat.2021.108648
    17. Kinnard EN, Bluthenthal RN, Kral AH, Wenger LD, Lambdin BH. The naloxone delivery cascade: Identifying disparities in access to naloxone among people who inject drugs in Los Angeles and San Francisco, CA. Drug Alcohol Depend. 2021;225:108759. doi:10.1016/j.drugalcdep.2021.108759
    18. Ohringer AR, Serota DP, McLean RL, Stockman LJ, Watt JP. Disparities in risk perception and low harm reduction services awareness, access, and utilization among young people with newly reported hepatitis C infections in California, 2018. BMC Public Health. 2021;21(1):1435. doi:10.1186/s12889-021-11492-3
    19. Lopez AM, Thomann M, Dhatt Z, et al. Understanding Racial Inequities in the Implementation of Harm Reduction Initiatives. Am J Public Health. 2022;112(S2):S173-S181. doi:10.2105/AJPH.2022.306767
    20. Being Antiracist. National Museum of African American History and Culture. Accessed March 2, 2022. https://nmaahc.si.edu/learn/talking-about-race/topics/being-antiracist
    21. Matsuzaka S, Knapp M. Anti-racism and substance use treatment: Addiction does not discriminate, but do we? J Ethn Subst Abuse. 2020;19(4):567-593. doi:10.1080/15332640.2018.1548323
    22. Roberts SK. The Politics of Stigma and Racialization in the Early Years of Methadone Maintenance Regulation. https://www.nationalacademies.org/event/03-03-2022/docs/DB9DE4A29281EB740DB6D3CAC55B1EFCB9FDB94AF835
    23. William L. White. Recovey-Oriented Methadone Maintenance. Published online 2010. http://www.williamwhitepapers.com/pr/dlm_uploads/2010Recovery_orientedMethadoneMaintenance.pdf
    24. Samet JH, Botticelli M, Bharel M. Methadone in Primary Care — One Small Step for Congress, One Giant Leap for Addiction Treatment. N Engl J Med. 2018;379(1):7-8. doi:10.1056/NEJMp1803982
    25. Peterkin A, Davis CS, Weinstein Z. Permanent Methadone Treatment Reform Needed to Combat the Opioid Crisis and Structural Racism. J Addict Med. 2022;16(2):127-129. doi:10.1097/ADM.0000000000000841
    26. Racial disparities in opioid addiction treatment: Primer & research roundup. The Journalist’s Resource. Published May 17, 2021. Accessed April 8, 2022. https://journalistsresource.org/home/systemic-racism-opioid-addiction-treatment/
    27. Goedel WC, Shapiro A, Cerdá M, Tsai JW, Hadland SE, Marshall BDL. Association of Racial/Ethnic Segregation With Treatment Capacity for Opioid Use Disorder in Counties in the United States. JAMA Netw Open. 2020;3(4):e203711. doi:10.1001/jamanetworkopen.2020.3711
    28. Rates of Drug Use and Sales, by Race; Rates of Drug Related Criminal Justice Measures, by Race | The Hamilton Project. Accessed March 2, 2022. https://www.hamiltonproject.org/charts/rates_of_drug_use_and_sales_by_race_rates_of_drug_related_criminal_justice
    29. Achieving Mental Health Equity: Addictions - Psychiatric Clinics. Accessed March 2, 2022. https://www.psych.theclinics.com/article/S0193-953X(20)30031-9/fulltext
    30. Krawczyk N, Picher CE, Feder KA, Saloner B. Only One In Twenty Justice-Referred Adults In Specialty Treatment For Opioid Use Receive Methadone Or Buprenorphine. Health Aff (Millwood). 2017;36(12):2046-2053. doi:10.1377/hlthaff.2017.0890
    31. Binswanger IA, Stern MF, Deyo RA, et al. Release from Prison — A High Risk of Death for Former Inmates. N Engl J Med. 2007;356(2):157-165. doi:10.1056/NEJMsa064115
    32. Access to Medications for Addiction Treatment for Persons Under Community Correctional Control. Default. Accessed March 2, 2022. https://www.asam.org/advocacy/public-policy-statements/details/public-policy-statements/2021/08/09/access-to-medications-for-addiction-treatment-for-persons-under-community-correctional-control
    33. Healthcare not Handcuffs. American Civil Liberties Union. Accessed March 2, 2022. https://www.aclu.org/issues/smart-justice/healthcare-not-handcuffs
    34. Treatment of Opioid Use Disorder in Correctional Settings. Default. Accessed March 2, 2022. https://www.asam.org/advocacy/public-policy-statements/details/public-policy-statements/2021/08/09/asam-public-policy-statement-on-treatment-of-opioid-use-disorder-in-correctional-settings
    35. Painting the Current Picture. National Drug Court Institute - NDCI.org. Accessed March 2, 2022. https://www.ndci.org/resources/painting-current-picture/
    36. Winchester ML, Shahiri P, Boevers-Solverson E, et al. Racial and Ethnic Differences in Urine Drug Screening on Labor and Delivery. Matern Child Health J. 2022;26(1):124-130. doi:10.1007/s10995-021-03258-5
    37. Gaither JR, Gordon K, Crystal S, et al. Racial disparities in discontinuation of long-term opioid therapy following illicit drug use among black and white patients. Drug Alcohol Depend. 2018;192:371-376. doi:10.1016/j.drugalcdep.2018.05.033
    38. Parental Substance Use: A Primer for Child Welfare Professionals - Child Welfare Information Gateway. Accessed March 2, 2022. https://www.childwelfare.gov/pubs/factsheets/parentalsubuse/
    39. Wakeman SE, Jordan A, Beletsky L. When Reimagining Systems Of Safety, Take A Closer Look At The Child Welfare System | Health Affairs. Accessed March 2, 2022. https://www-healthaffairs-org.proxy.library.georgetown.edu/do/10.1377/forefront.20201002.72121/
    40. Children’s Bureau: An Office of the Administration for Children and Families, Child Welfare Information Gateway. Child Maltreatment 2019: Summary of Key Findings. Published online April 2021:8.
    41. Roberts SCM, Nuru-Jeter A. Universal screening for alcohol and drug use and racial disparities in child protective services reporting. J Behav Health Serv Res. 2012;39(1):3-16. doi:10.1007/s11414-011-9247-x
    42. Colmorgen GHC, Johnson C, Zazzarino MA, Durinzi K. Routine urine drug screening at the first prenatal visit. Am J Obstet Gynecol. 1992;166(2):588-590. doi:10.1016/0002-9378(92)91679-5
    43. Legal interventions during pregnancy. Court-ordered medical treatments and legal penalties for potentially harmful behavior by pregnant women. JAMA. 1990;264(20):2663-2670.
    44. Opposition to Criminalization of Individuals During Pregnancy and the Postpartum Period. Accessed March 7, 2022. https://www.acog.org/en/clinical-information/policy-and-position-statements/statements-of-policy/2020/opposition-criminalization-of-individuals-pregnancy-and-postpartum-period
    45. Chasnoff IJ, Landress HJ, Barrett ME. The Prevalence of Illicit-Drug or Alcohol Use during Pregnancy and Discrepancies in Mandatory Reporting in Pinellas County, Florida. N Engl J Med. 1990;322(17):1202-1206. doi:10.1056/NEJM199004263221706
    46. Movement for Family Power. Ground Zero. Mov Fam Power. Published online 2022. Accessed March 7, 2022. https://www.movementforfamilypower.org/ground-zero
    47. Child Welfare Practice to Address Racial Disproportionality and Disparity - Child Welfare Information Gateway. Accessed March 2, 2022. https://www.childwelfare.gov/pubs/issue-briefs/racial-disproportionality/
    48. Centers for Disease Control and Injury Prevention. About Social Determinants of Health (SDOH). Published March 10, 2021. Accessed May 31, 2022. https://www.cdc.gov/socialdeterminants/about.html
    49. Schickedanz A, Hamity C, Rogers A, Sharp AL, Jackson A. Clinician Experiences and Attitudes Regarding Screening for Social Determinants of Health in a Large Integrated Health System. Med Care. 2019;57(Suppl 6 2):S197-S201. doi:10.1097/MLR.0000000000001051
    50. Addressing Social Determinants: Scaling Up Partnerships With Community-Based Organization Networks | Health Affairs. Accessed March 2, 2022. https://www-healthaffairs-org.proxy.library.georgetown.edu/do/10.1377/forefront.20200221.672385/full/
    51. On Racism: A New Standard For Publishing On Racial Health Inequities | Health Affairs Forefront. Accessed March 2, 2022. http://www.healthaffairs.org/do/10.1377/forefront.20200630.939347/full/
    52. Disparity of Race Reporting and Representation in Clinical Trials Leading to Cancer Drug Approvals From 2008 to 2018 | Health Disparities | JAMA Oncology | JAMA Network. Accessed March 2, 2022. https://jamanetwork-com.proxy.library.georgetown.edu/journals/jamaoncology/fullarticle/2748395
    53. Race, Ethnicity, and NIH Research Awards. Accessed March 2, 2022. https://www-science-org.proxy.library.georgetown.edu/doi/10.1126/science.1196783
    54. Topic choice contributes to the lower rate of NIH awards to African-American/black scientists. Accessed March 2, 2022. https://www-science-org.proxy.library.georgetown.edu/doi/10.1126/sciadv.aaw7238
    55. Vyas DA, Eisenstein LG, Jones DS. Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms. N Engl J Med. 2020;383(9):874-882. doi:10.1056/NEJMms2004740
    56. TIP 57: Trauma-Informed Care in Behavioral Health Services | SAMHSA Publications and Digital Products. Accessed March 2, 2022. https://store.samhsa.gov/product/TIP-57-Trauma-Informed-Care-in-Behavioral-Health-Services/SMA14-4816
    57. Trauma-Informed Care. Accessed March 2, 2022. https://www.ahrq.gov/ncepcr/tools/healthier-pregnancy/fact-sheets/trauma.html
    58. Chaudhri S, Zweig KC, Hebbar P, Angell S, Vasan A. Trauma-Informed Care: a Strategy to Improve Primary Healthcare Engagement for Persons with Criminal Justice System Involvement. J Gen Intern Med. 2019;34(6):1048-1052. doi:10.1007/s11606-018-4783-1
    59. Marsac ML, Kassam-Adams N, Hildenbrand AK, et al. Implementing a Trauma-Informed Approach in Pediatric Health Care Networks. JAMA Pediatr. 2016;170(1):70-77. doi:10.1001/jamapediatrics.2015.2206
    60. MPH MT MD. Trauma-informed care: What it is, and why it’s important. Harvard Health. Published October 16, 2018. Accessed March 2, 2022. https://www.health.harvard.edu/blog/trauma-informed-care-what-it-is-and-why-its-important-2018101613562
    61. Gomez LE, Bernet P. Diversity improves performance and outcomes. J Natl Med Assoc. 2019;111(4):383-392. doi:10.1016/j.jnma.2019.01.006
    62. Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139(11):907-915. doi:10.7326/0003-4819-139-11-200312020-00009
    63. Johnson RL, Saha S, Arbelaez JJ, Beach MC, Cooper LA. Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med. 2004;19(2):101-110. doi:10.1111/j.1525-1497.2004.30262.x
    64. Nair L, Adetayo OA. Cultural Competence and Ethnic Diversity in Healthcare. Plast Reconstr Surg Glob Open. 2019;7(5):e2219. doi:10.1097/GOX.0000000000002219
    65. Garcia ME, Coffman J, Jordan A, Martin M. Lack of Racial and Ethnic Diversity Among Addiction Physicians. J Gen Intern Med. Published online January 31, 2022. doi:10.1007/s11606-022-07405-8
    66. Morris DB, Gruppuso PA, McGee HA, Murillo AL, Grover A, Adashi EY. Diversity of the National Medical Student Body — Four Decades of Inequities. N Engl J Med. 2021;384(17):1661-1668. doi:10.1056/NEJMsr2028487
    67. Guevara JP, Wade R, Aysola J. Racial and Ethnic Diversity at Medical Schools — Why Aren’t We There Yet? N Engl J Med. 2021;385(19):1732-1734. doi:10.1056/NEJMp2105578
    68. The ASAM Appropriate Use of Drug Testing Consensus Document. Default. Accessed March 2, 2022. https://www.asam.org/quality-care/clinical-guidelines/drug-testing
    69. Jordan A, Jegede O. Building Outreach and Diversity in the Field of Addictions. Am J Addict. 2020;29(5):413-417. doi:10.1111/ajad.13097
    70. Legal Action Center | New Report from the Legal Action Center Finds…. Legal Action Center. Accessed January 19, 2022. https://www.lac.org/news/new-report-from-the-legal-action-center-finds-that-denying-necessary-care-for-substance-use-disorders-in-emergency-departments-can-violate-federal-law
    71. Rusch D, Frazier SL, Atkins M. Building Capacity Within Community-Based Organizations: New Directions for Mental Health Promotion for Latino Immigrant Families in Urban Poverty. Adm Policy Ment Health Ment Health Serv Res. 2015;42(1):1-5. doi:10.1007/s10488-014-0549-1
    72. Gilligan HT. Beyond Research, Taking Action Against Racism. Health Aff (Millwood). 2022;41(2):158-162. doi:10.1377/hlthaff.2021.02040
    73. Assessment of Disparities in Digital Access Among Medicare Beneficiaries and Implications for Telemedicine | Health Disparities | JAMA Internal Medicine | JAMA Network. Accessed March 2, 2022. https://jamanetwork-com.proxy.library.georgetown.edu/journals/jamainternalmedicine/article-abstract/2768771
    74. Weber E, Miller SJ, Astha V, Janevic T, Benn E. Characteristics of telehealth users in NYC for COVID-related care during the coronavirus pandemic. J Am Med Inform Assoc. 2020;27(12):1949-1954. doi:10.1093/jamia/ocaa216
    75. Beyond Declarative Advocacy: Moving Organized Medicine And Policy Makers From Position Statements To Anti-Racist Praxis | Health Affairs Forefront. Accessed March 2, 2022. http://www.healthaffairs.org/do/10.1377/forefront.20210219.107221/full/
    76. Alegria M, Frank R, Hansen H, Sharfstein J, Shim R, Tierney M. Transforming Mental Health And Addiction Services | Health Affairs. Published January 21, 2021. Accessed March 2, 2022. https://www-healthaffairs-org.proxy.library.georgetown.edu/doi/10.1377/hlthaff.2020.01472?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

       


      [*] Scholars have advocated for use of the term “minoritized,” which is used to refer to the same shared experience of exposure to systemic and individual racism in health and beyond and provides an understanding that people are actively minoritized by others, rather than naturally existing as a minority, as the terms racial or ethnic minorities imply.

      [†] In the first policy statement in this series, the cited definition of “structural competency” is “the capacity… to recognize and respond to health and illness as the downstream effects of broad social, political, and economic structures.”