Cultural Issues in Substance Abuse Treatment Russell F. Lim, MD Associate Clinical Professor UC Davis School of Medicine Department of Psychiatry & Behavioral Sciences firstname.lastname@example.org 38th Semi-Annual Substance Abuse Research Consortium (SARC) Meeting, Sacramento, CA, September 23, 2008
Agenda-1 • APA Practice Guidelines for the: • Treatment of Patients with Substance Use Disorders, 2nd ed., 2006 • Psychiatric Evaluation of Adults, 2nd ed., 2006 • Substance abuse in special populations • The DSM-IV-TR Outline for Cultural Formulation • Ethnocultural Factors in Substance Abuse Treatment, Straussner, 2001
Agenda-2 • TIP 40- Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction, 2004 • TIP 42- Substance Abuse Treatment for Persons With Co-Occurring Disorders (COD), 2005 • TIP 47- Substance Abuse: Clinical Issues in Intensive Outpatient Treatment, 2006
General Assessment Principles: Clinical Factors-1 • The number and type of substances used • The individual's genetic vulnerability for developing a substance use disorder (s) • The severity of the disorder, the rapidity with which it develops, and the degree of associated functional impairment (s) • The individual's awareness of the disorder as a problem
General Assessment Principles: Clinical Factors-2 • The individual's readiness for change and motivation to enter into treatment for the purpose of change • The associated general medical and psychiatric conditions (either co-occurring or induced by substance use) • The individual's strengths (protective and resiliency factors) and vulnerabilities • The social, environmental, and cultural context in which the individual lives and will be treated
Characteristics of Substance Abuse Disorders in Women-1 • Information on the natural history, clinical presentation, physiology, and treatment of substance use disorders in women is limited. • 34% of all individuals with a substance use disorder other than nicotine dependence in the U.S. • Women's low utilization of substance use disorder treatment services may be related to:
Characteristics of Substance Abuse Disorders in Women-2 • Psychosocial and financial barriers (e.g., lack of child care, lack of health insurance) prevent many women from seeking treatment. • Women's perception of greater social stigma associated with their substance abuse.
Characteristics of Substance Abuse Disorders in Women-3 • Higher prevalence than men of primary co-occurring mood and anxiety disorders that require psychiatric care. • Many women with a substance use disorder have a history of physical and/or sexual abuse (both as children and as adults). • Poorer prognosis for medical sequelae of alcohol abuse and dependence in women.
Characteristics of Substance Abuse Disorders in Women-4 • Alcohol-dependent women consume less alcohol than men yet progress to late stages of alcohol-related illness more rapidly. • Shorter time course to the initial development of alcohol-related medical morbidity than do men. • Prevalence rates of alcohol-related cirrhosis of the liver and cardiomyopathy in women are twice that in men.
Characteristics of Substance Abuse Disorders in Women-5 • Women frequently initiate cocaine and opioid use in the context of a substance-using partner and tend to initiate use at a younger age than men. • Tailoring the goals of treatment to meet the needs of women improves treatment outcomes for substance-using women.
Characteristics of Substance Abuse Disorders in Adolescents-1 • Alcohol and other psychoactive substance use, abuse, and dependence in children and adolescents presents a serious public health problem in the US. • Substance abuse is among the leading causes of morbidity and mortality from motor vehicle accidents, suicidal behavior, violence, drowning, and unprotected sexual activity.
Characteristics of Substance Abuse Disorders in Adolescents-2 • Regional studies reveal that 7%-10% of adolescents are in need of treatment for substance use disorders. • Dual diagnosis is common in most adolescents with substance use disorders, most often conduct disorder and/or major depression, although ADHD, anxiety disorders (social phobia and PTSD), bipolar disorder, eating disorders, learning disabilities, and axis II disorders.
Characteristics of Substance Abuse Disorders in Adolescents-3 • Outcomes for adolescents appear to be enhanced by the availability of treatment that is developmentally appropriate and peer oriented and includes educational, vocational, and recreational services. • Family therapy also appears to have benefit.
Characteristics of Substance Abuse Disorders in Elderly Individuals-1 • Substance use disorders in elderly individuals are often undiagnosed and under-treated. • Abuse of and dependence on prescribed medications, particularly benzodiazepines, sedative-hypnotic medications, and opioids.
Characteristics of Substance Abuse Disorders in Elderly Individuals-2 • Alcohol use disorders, whether an extension of a long-standing disorder or of later onset, are a major problem among elderly individuals, particularly those living alone. • A large multi-site study (PRISM-E) has shown that elderly primary care patients screening positive for a substance use disorder prefer to be treated within the medical system, with integrated treatment (Bartels SJ, 2004).
Characteristics of Substance Abuse Disorders in Elderly Individuals-3 • VA patients age 54 years or older who received specialized services for elderly patients as part of a treatment program were four times more likely to complete the program and remained in treatment longer than those who received conventional services. (Kofoed LL,1987)
Characteristics of Substance Abuse Disorders in Cultural Groups • Treatment services that are culturally sensitive and address the special concerns of ethnic minority groups may improve acceptance of, adherence to, and, ultimately, the outcome of treatment. • Current research suggests poorer prognoses for ethnic and racial minorities in conventional treatment programs, although this may be accounted for by socioeconomic group differences.
Substance Abuse Disorders: Issues in Hispanic Americans
Hispanic Americans-1 • Second largest ethnic group in USA • Mexican-Americans, Puerto Ricans, Cuban-Americans, and immigrants from Central and South American countries • Heterogeneous
Hispanic Americans-2 • Emphasis on family • Religious influences • Tradition of folk healers • Gender roles • Styles of communication
Barriers to treatment • Language • Inability of staff to earn confianza • Geographic • Criminal justice system • Lack of Hispanic physicians • Lack of insurance • Legal status
Treatment Issues • Hispanics drop out of some types of drug abuse treatment programs at higher rates than Anglos (DeLeon,et al, 1992) • Focus of treatment should emphasize family values, cultural background • Culturally appropriate assessment and engagement is critical • Therapeutic alliance is key
Effective substance abuse treatment for Hispanics • Involve extended family • Use of folk healers • Support of church • Support of merchants, civic organizations • Respeto, dignidad, personalismo
Substance Abuse Disorders: Issues in African Americans
African Americans • Importance of religion and spirituality • Extended family network • Disproportional high rate of poverty • Concerns about racial discrimination • Concerns about privacy
African Americans-Barriers to Help Seeking • Concerns about stigma • Mistrust of health professionals • Belief that prayer alone can heal • Belief that suffering is a part of life for Black people • Criminal justice system
African Americans-Adequacy of Treatment Services-1 • Trust issues in therapeutic relationships • Cultural sensitivity of care providers • Ethnically appropriate assessment of client behavior, symptoms and needs Cultural Issues in Substance Abuse Treatment CSAT, 1999
African Americans-Adequacy of Treatment Services-2 Additional services to consider (cont.) • On site twelve-step programs attended by members from the ethnic groups in the area • Employment of appropriate ethnic staff at all levels • Involvement of professional and paraprofessional counselors from the recovering community Cultural Issues in Substance Abuse Treatment CSAT, 1999
Substance Abuse Disorders in Asian Americans
Introduction to Asian Americans Many groups (43) and languages with separate cultures- Heterogeneous Asian/Pacific Americans are one of the fastest growing ethnic minority groups Major groups Chinese Filipino Japanese Korean Substance abuse is under-reported due to shame and stigma • Southeast Asian (Vietnamese, Cambodian, Laotian, Hmong, Mien) • South Asian
Epidemiology Published data shows low incidence Lack of comprehensive data on many groups-not included in many studies Heterogeneity makes drawing conclusions difficult Language is a barrier Stigma and shame
Risk Factors Acculturation stress Increased freedom Alienation from parent culture Access to alcohol and drugs Traumatic experiences Personal losses; loss of supports
Assessment Issues Be familiar with the immigration history of the group General knowledge-Cultural norms Specific knowledge-Migration history Cultural consultation Delay screening of habits
Treatment Issues Know the cultural values Bilingual and bicultural staff Trauma issues in immigrants Awareness of shame and stigma Community based treatment Using culturally acceptable treatment approaches
Substance Abuse Disorders: Issues in American Indians Sarah Penman, Buck Bear Heart, Lakota Nation, South Dakota, 1998
Historical and Sociocultural Factors Impact of Colonization • Loss of knowledge and traditions • Impact of disease from colonial contact • Forced relocation from the land • Removal of children from the family
Demographics-1 • Over 560 federally recognized tribes • Over 250 distinct languages among tribes • Most American Indians live in Western States • 44% live in rural areas
Demographics-2 • (1997-99) 26% live in poverty • Life expectancy 63.5 years • Median age 27.8 years • (1990 –01) population increased 22.4% to 2.5 million
Epidemiology-1 • 5th leading cause of death chronic liver disease and cirrhosis ( MMWR,CDC, 1994-96 ) • 20% 12 – 17 yr olds illicit drug use (SAMSHA Household Survey , 1999) • Death rates due to alcoholism 7 x greater then general population • Suicide 1.5 x national rate
Epidemiology-2 • 70% with lifetime alcohol disorder and psychiatric disorder (Robin et.al 1997) • Fetal Alcohol Syndrome rate 3x higher than for all other groups 2.97 per 1,000 births (CDC , 1998) • PTSD prevalence rate 2.75 x higher than general population (Kessler et al., 1995)
Surgeon General’s Recommendations • Improve Access to Treatment • VA/Tribal Outreach Projects-PTSD, Depression, Substance Abuse highly co-morbid. Natives teach Natives. • Reduce Barriers to Care • Tribal Health Programs • Chapter Houses, Lodges • Medicine Person/ Healers • Sweat Lodge, Ceremonies • Community Fairs, Pow Wow’s, Rodeo Circuit • Denver Pow Wow – Eagle Lodge (Residential Drug and Alcohol)sponsors dancers & crafts booth