STASH, Vol. 20(10) – Opioid overdose survivors’ experiences with substance use treatment in Boston

In the United States, drug-related overdoses disproportionately affect marginalized racial and ethnic groups. While Massachusetts residents have access to harm reduction services, such as medications for opioid use disorder (MOUD) within primary care settings and low-barrier transitional housing, Black residents are still less likely to receive treatment services compared to White residents. This week, STASH reviews a study by Ranjani K. Paradise and colleagues that used a racial equity lens to analyze opioid overdose survivors’ experiences accessing and engaging in substance use treatment services in Boston, Massachusetts.

What were the research questions?
What factors contribute to racial/ethnic disparities in substance use treatment access and engagement among opioid overdose survivors in Boston, MA?

What did the researchers do?
With community-based organizations, the researchers used purposive sampling to recruit 59 participants over the age of 18 who self-identified as Black, Latino/a/x, or White, spent the past 30 nights in Boston, and experienced an opioid overdose within the past 3 months. Participants reported their drug use and overdose histories. They were interviewed about their experiences and viewpoints on overdose prevention and treatment services. The researchers coded participants’ responses using a thematic analysis to identify factors related to racial/ethnic inequities in accessing and engaging with these services.

What did they find?
Factors at individual, interpersonal, program/process, and systems levels impacted treatment access and engagement. Some factors were more prominent among Black and Latino/a/x participants compared to White participants. At the individual level, Black and Latino/a/x participants shared more critical views of MOUD than White participants (see Figure). At the interpersonal level, participants overall shared experiences of bias and stigma that they attributed to their addiction and housing insecurity, but Black and Latino/a/x participants also faced racial/ethnic stigma and prejudice. They also expressed difficulties connecting to services after an overdose, unlike White participants (program/process level). Lastly, systemic barriers like lack of housing, employment, and mental healthcare impacted treatment access and engagement, with housing being a primary concern among all racial/ethnic groups.

Figure. Themes identified by participants organized by socio-ecological level (i.e., individual, interpersonal, program/process, and systems levels). Items indicated in bold were expressed specifically by Black and/or Latino/a/x participants. Click image to enlarge.

Why do these findings matter?
To reduce stigma in substance use treatment settings, these services should be managed by a diverse workforce, including individuals who have been marginalized by their race, ethnicity, and/or addiction experience. Providers should also be educated on how racism and bias affect treatment engagement. This study’s findings suggest that factors rooted in systemic racism that contribute to racial/ethnic disparities in overdose rates (e.g., housing insecurity, drug policies, lack of access to harm reduction services) also drive disparities in treatment access and engagement. Policymakers should address systemic stigma in the criminal justice system and MOUD treatment policies. To achieve this, we need to reframe opioid overdose as a public health issue rather than a moral failing and better integrate substance use care, including MOUD, into general medical care.

Every study has limitations. What are the limitations in this study?
The findings might not be generalizable to people from other neighborhoods, racial/ethnic backgrounds, or those with stable housing. Additionally, the researchers were unable to draw strong conclusions about the racial/ethnic subgroup differences because of the small sample size.

For more information:
Community Voices in Recovery is a free, online course for allied health professionals who want to improve racial and health equity in addiction care. If you are worried that you or someone you know is experiencing addiction, the SAMHSA National Helpline is a free treatment and information service available 24/7.  For additional self-help tools, please visit our Addiction Resources page.

— Nakita Sconsoni, MSW