Racial Disparities in Drug Intervention: Culturally Inclusive Approaches

In this episode, APS’s Özge Gürcanlı Fischer Baum discusses culturally sensitive and inclusive treatments with experts William Stoops from the University of Kentucky Medical Center, along with his colleagues Jardin Dogan-Dixon and Danelle Stevens-Watkins from the University of Kentucky, Paris Wheeler from the University of Cincinnati, and Krystal Cunningham from Boston College.  

Together, they examine evidence-based drug treatment studies, highlighting racial disparities in treatment effectiveness, especially how Black participants often experience worse outcomes than White participants. The discussion includes the impact of systemic racism, the opioid versus cocaine overdose epidemics, and the differences between culturally tailored and universal interventions. 

Send us your thoughts and questions at  [email protected].

Unedited transcript

[00:00:08.840] – APS’s Özge Gürcanlı Fischer Baum

How can researchers and practitioners ensure that treatments are culturally sensitive and inclusive? I’m Özge Gürcanlı Fischer Baum with the Association for Psychological Science. In today’s episode, we are diving into evidence-based drug treatment studies that have significantly shaped best practices in the United States. Our focus will be on the racial disparities in the effectiveness of these treatments, particularly how black participants often report worse outcomes compared to white participants. Today, I have the pleasure of talking to William Stoops from the University of Kentucky Medical Center. He is joined by his colleagues, Jardin Dogan-Dixon and Danelle Stevens-Watkins from the University of Kentucky, Paris Wheeler from the University of Cincinnati, and Krystal Cunningham from Boston College. They recently published an article on culturally tailored treatment approaches. Bill, Jardin, Danelle, Paris, and Krystal, welcome to Under the Cortex.

[00:01:12.180] – William Stoops

Thank you so much for having us. We’re really happy to be here today. Yeah.

[00:01:16.130] – APS’s Özge Gürcanlı Fischer Baum

So Bill, let’s start with you. You have a great team here. Could you introduce your team to us?

[00:01:21.360] – William Stoops

I do. I’ve got a terrific team. So I will start by saying this paper idea arose from work we were doing in our laboratory, looking at contingency management, which we’re going to talk about in just a little bit for treating people with cocaine use disorder. I have long been friends and collaborators with Dr. Stevens-Watkins, and I needed to hire talented clinicians to work with my participants. I was able to bring on both Dr. Dogan-Dixon and Dr. Wheeler, before they were doctors, as master’s-level counselors for my participants. And then Ms. Cunningham joined a little later as we were writing the paper. I’ve never had the opportunity to actually have her work in our lab, but maybe someday. As Jardin and Paris were working in my lab, we just decided we wanted to write some papers about cocaine use disorder. And the idea really originated from Jardin to write this review to try to understand treatment of cocaine use disorder in black people or people of African-American descent in the United States.

[00:02:24.220] – APS’s Özge Gürcanlı Fischer Baum

Thank you very much for the introduction. This is such an important topic, and I would like our listeners to understand all the hard work that went into that. So drug overdose continues to be a pervasive problem in the United States. What does the landscape of overdose and addiction look like these days?

[00:02:44.940] – William Stoops

Yeah, So it’s a very obviously complex societal issue. There are health issues behind it. There are racial issues behind it. There’s just a bunch of things going on. But I think at its core, the overdose crisis is driven by a couple of different things. First is opioid overdose, right? That somebody takes an opioid like fentanyl or heroin, and they stop breathing, and then they overdose. And if we can rescue them with naloxone, that’s great. They come back, but sometimes we can’t, and they die. We also see stimulant overdose, which would be cocaine or methamphetamine overdose. A lot of stimulant overdoses are actually opioid overdoses in disguise because those stimulant drugs like cocaine or methamphetamine can be adulterated with an opioid. Although polydrug use is the norm, many people who are using one drug are using another drug. Lots of times people who use stimulants aren’t using opioids. They don’t have any tolerance to opioids. So if they’re using an adulterated drug, they will overdose on opioids when they think they’re using stimulants. But there’s another piece of stimulant overdose, and I’m using scare quotes here, in that people who die from stimulants, it’s not necessarily an overdose.

[00:03:58.100] – William Stoops

It really is a talk toxicity that builds up over time. Stimulants can be very harmful to the body in the long term. They hurt the heart, they hurt other organs. And so when we talk about a stimulant overdose, again, using the scare quotes, it’s really more somebody having a seizure or a stroke after longer term use. So that’s the landscape we’ve got, right? An opioid, acute overdose, or chronic use of stimulants leading to overdose. And sometimes it’s both.

[00:04:28.660] – APS’s Özge Gürcanlı Fischer Baum

So, yeah, we are then talking about both overdose, like you said, and also long term effects on our health. Which brings me to my follow up question, how does the systemic racism in our justice system make this problem particularly difficult for black people? Danelle, what do you think about this?

[00:04:45.810] – Danelle Stevens-Watkins

This has historically been a problem, particularly for black Americans, in the criminalization of drug use, in which in other populations in the US, drug use has historically been seen as illness, as a medical problem. However, in many black communities, and particularly black populations, drug use has been criminalized. Being able to come forward and acknowledge your drug use is always a challenge for black participants for fear of legal repercussions and other societal repercussions. In addition, particularly for black women, loss of custody their children. All of these things make it very difficult for black Americans to come forward and seek and retain stay in treatment.

[00:05:44.790] – APS’s Özge Gürcanlı Fischer Baum

That’s why you mentioned this culturally sensitive treatments. We will come to that. But I have another question. When we talk about the overdose epidemic, we usually hear about opioids, but people usually don’t talk about the cocaine overdose epidemic. Why do you think that is?

[00:06:06.390] – Paris Wheeler

I think that is a a complicated question because I think that sometimes they are both talked about. They’re just talked about very differently. Ultimately, structural and systemic racism underlies how things are talked about. As Dr. Stevens-Watkins just mentioned, during the war on drugs, cocaine use, particularly cocaine use by Black individuals was very much demonized and criminalized. Because it was disproportionately impacting Black communities in that way, it was not really viewed as like, We need to help people get into treatment. It was more of, We are going to criminalize people for their use. However, when the opioid crisis really started escalating, because at first it was disproportionately impacting white, rural, and suburban populations, it was noticeably a much more compassionate and treatment-focused conversation happening. People were more focused on how do we develop policies to help save lives and get people the services they need versus everybody gets sent straight to jail. For that reason, I think they are both talked about, just talked about quite a bit differently. Then similar to what Bill was saying, I think that the two crises are more overlapping than anything. So many people who use cocaine and other stimulants are inadvertently being exposed to opioids.

[00:07:30.310] – Paris Wheeler

It’s becoming almost like a dual epidemic that’s happening to people at the same time.

[00:07:37.560] – APS’s Özge Gürcanlı Fischer Baum

Yeah. Thank you, Paris, for your answer for that. Let’s talk about the study a little bit. It is great work. Thank you for your hard work. When you go through different types of treatments in the paper, you will talk about the contingency management one as being the most effective treatment for reducing cooking use in the general population. My question is, what is that treatment like? What makes it so powerful? Bill, what do you think?

[00:08:09.660] – William Stoops

Sure. So contingency management is a behaviorally-based intervention, and it’s really focused on or it’s really founded in operant psychology, reinforcing behavior. And so the clever thing about it is that you aren’t punishing anything. You aren’t punishing drug use. What you’re doing is you’re reinforcing engagement in non-drug use behaviors. And this is a research treatment. But I will note that states are starting to adopt this as an evidence-based treatment. So the way it works, and there are a number of different iterations, but at the end of the day, you enroll people who are treatment-seeking, who use stimulants, and you educate them on the target behavior you’re seeking. And lots of times that is abstinence from cocaine or methamphetamine from the stimulant. And you tell them, and you let them know that when they provide objective evidence, usually it’s a urine sample, but it can be a blood sample or a saliva sample. Negative for cocaine or methamphetamine, they receive a reinforcer. It’s often money, but it can be clinic privileges. It can be access to friends, family, social reinforcers. But really, the idea is you are encouraging non-drug use behavior by reinforcing it. It’s really pretty simple at the end of the day.

[00:09:27.280] – William Stoops

And I think it’s so powerful because we are all organisms just behaving in our environment. And I think that for people with stimulant use disorder, we don’t have a medication to treat them with. We don’t have a medication to reverse overdose, but we can offer them these alternatives. And lots of times, I think some of it is they don’t have access to a lot of alternatives. So this treatment provides alternatives, provides some freedom and some funds to do non-drug related activities and behaviors. And I think that’s part of why it’s so powerful.

[00:10:00.440] – APS’s Özge Gürcanlı Fischer Baum

But it is not as effective for black Americans. Could you talk a little bit about that? And what are the numbers like there?

[00:10:11.010] – William Stoops

I think that’s an open question. Of course, our review covers contingency management and looking at contingency management in black populations. I would say I would want to gather more data on why it might not be as effective for groups. But I think some of the answers about why we know other treatments are as well responded to in black populations might be an answer here. This is a research treatment, and we have a long history in the medical profession of mistreating black people. And so it could be just a general reticence to engage in a research treatment. I don’t think it’s anything that black people don’t respond to reinforcers. They obviously do. They obviously want to engage in treatment. But I think it’s probably something systemic and larger. But I will caveat that by saying, I don’t know the answer.

[00:10:58.560] – APS’s Özge Gürcanlı Fischer Baum

Right. But it is a It’s part of a research project, right? It is a whole research program. So just diagnosing that this is not the best treatment for Black Americans is an amazing starting point. Yeah. So let’s talk a little bit about other types of interventions. What are some key differences between culturally tailored and culturally universal interventions? Let me also ask, what about the culturally tailored treatments made them so effective? Krystal, what do you think about this?

[00:11:30.000] – Krystal Cunningham

So specifically, when I think about culturally tailored treatment interventions, I’m thinking about two things, really. So the first being that they’re less likely to seek treatment, complete it, and then abstain afterwards. And so when we look at Black populations, they have different stressors that they’re facing and different barriers to treatment. And so that’s the first part of making sure that we address that so that they’re getting into treatment. And then once they’re in treatment, it’s important to take their culture into to account and to use things that they find strength from in treatment, because that’s more likely to be effective. An example of that being spirituality in whatever form. That tends to be a cultural strength of Black Americans. And then when I think about stressors that lead people to use substances, they… Substance use generally is a response to larger problems that are happening in someone’s life. And When we think about the stressors that black Americans face that are different from the rest of the population, such as systemic racism, if we’re treating the response and not addressing why the response has occurred, then it’s just less likely to be effective. Those are the kinds of things that I think are the components that can make it more effective for them.

[00:12:51.070] – APS’s Özge Gürcanlı Fischer Baum

And some of these studies that are mentioned in the article, we see that Black participants don’t necessarily fare in these programs compared to the overall population. For example, motivational interviewing didn’t seem to work well with Black populations. So do they work well for anyone? And do we see the discrepancy here? Jardin, what are your thoughts about that?

[00:13:17.300] – Jardin Dogan-Dixon

When we conceptualize this project, we want to be really intentional about focusing on Black populations, primarily because some of the substance use research that has pre-existed really either focused on a color-blind, didn’t aggregate the data based on sex or race. When it did, it was very in comparison language. And so recognizing, as my colleagues have talked about how the opioid epidemic and the cocaine epidemic are co-occurring and are disproportionately affecting Black people, we really wanted to give equitable attention to this population. So that’s how we steered away from really using comparison type language. But in regards to motivational interviewing, much like contingency management and CVT, it is an evidence-based approach. It’s sponsored by SAMHSA. It’s really evidence-based, and people push it, and it’s great. It’s been shown to be moderately effective for increasing folks in internal motivation to change and at least helping them engage in treatment. But I think long term and over time, we see less effectiveness in the sustaining of the abstinence of drug use. And that may be because in the beginning, you’re simply trying to people motivated to change, but it may not continue that change over time or sustain it.

[00:14:35.900] – Jardin Dogan-Dixon

I think research suggests, and I think people can see in the paper that, motivational interviewing in conjunction or combined with another evidence-based approach like CBT or contingency management, seems to be a little bit more effective over time versus just in the initial process of treatment.

[00:14:54.750] – APS’s Özge Gürcanlı Fischer Baum

This review article does a great service to everyone involved in this epidemic. One of the important things, as we talked about earlier, is just diagnosing what works and what doesn’t work and why is the next step. Based on what you learned during this review. If you could have funding to test a treatment program focused on Black adults, what would you want to do?

[00:15:21.610] – Jardin Dogan-Dixon

I love that question. I think that’s a miracle question. Give me all the money so that I can do all the things. But I think, ideally, I think based off of this research, it’s really important that we start to integrate cultural components into substance use treatment. One thing I noticed in doing the paper and coding was that there wasn’t a combination or a cultural adaptation to evidence-based approaches. If it was, they were very rare and scarce in the literature. I think it would be really cool to see how we incorporate, let’s say, spirituality and community and faith-based approaches with CBT integrated treatment to merge or marry those two things together and bring back cultural adaptation to the interventions that we have. I think the cultural components are absolutely necessary when working with Black individuals.

[00:16:12.900] – APS’s Özge Gürcanlı Fischer Baum

Anyone else who wants to answer this?

[00:16:16.160] – Paris Wheeler

I am very much in agreement with Jardin that being able to integrate these cultural factors into existing evidence-based approaches would be great. I think if we had all the money in the world, I would also want to integrate a lot of structural interventions into it as well. I often feel super overwhelmed when answering this question because the more I learn, the more I realize that there’s just so much outside of the individual that’s impacting their outcomes besides the things that we, as psychologists, are traditionally trained to address. I would want to also include in this culturally adapted intervention, making sure people have access to reliable transportation to be able to get to the treatment If they have any form of houncing, insecurity or instability, that they have secure housing while they’re participating in the treatment and/after. Access to healthy food if they need it. Making sure that all of those other external contextual things that are impacting how they even move through the day in their capacity to even be able to engage with treatment, making sure all those things are also taken care of in addition to being able to meet them where they’re at culturally while we’re doing this treatment.

[00:17:28.130] – Paris Wheeler

Obviously, that’s It’s such a huge thing to be able to do. But thinking about if we had all the money in the world, I feel like that ultimately would be such a cool thing to be able to address as well.

[00:17:38.320] – APS’s Özge Gürcanlı Fischer Baum

Yeah, Paris, you raised really important points. If you cannot get to the treatment comfortably, How is it going to work? We really need to think about all the systemic barriers as well to have access to these treatments, too. Well, unfortunately, we don’t have all the unlimited resources in the world. If you were to talk to the policymakers with their limited resources, what would you tell them? What steps can policymakers take to address the racial disparities in drug treatment outcomes? Danelle, what do you think about this?

[00:18:16.450] – Danelle Stevens-Watkins

Yes, so that’s a great question, particularly given the current political landscape. I think first, I would say it’s really important that we not go backwards in terms of funding this work and recognizing the importance of this work. That is a critical key piece in order for us to make any gains and improve overdose and deaths in the black community. So I know my colleagues have other pieces to add here, but the key thing is we’ve made a lot of progress in the past 20 years. Let’s not go backwards.

[00:18:51.790] – Paris Wheeler

Yeah.

[00:18:52.740] – APS’s Özge Gürcanlı Fischer Baum

Bill, do you have anything to add?

[00:18:54.660] – William Stoops

I think the other thing, maybe just a couple of things I would add is, Danelle said this very we’ve criminalized a medical condition. So I think that, particularly in the black community, but overall as well. And so I think the policymakers need to understand that we are not going to jail our way out of this issue. But then the other thing I would say, and if it’s not obvious already, I’m a real fan of contingency management. It’s, again, the most effective treatment for stimulant use disorder. And I would encourage… Some states are starting to roll it out as a pilot project. California is probably the most famous one. But the Biden administration has indicated that we need to roll it out as an evidence-based practice nationally. I think that that is something policymakers really have to put some will behind. It’s being used in the VA. It’s being piloted in some states, but that’s not enough. And so we need as a country, to have our policymakers help us write that roadmap to get this effective treatment actually delivered to people.

[00:19:53.230] – APS’s Özge Gürcanlı Fischer Baum

Is there anything else that you would like to share with our listeners?

[00:19:57.920] – William Stoops

I would just say thank you for your time and interest, and I’m really just proud of this team and the work that we’ve done, and I can’t wait to figure out what we’re going to do next.

[00:20:05.490] – APS’s Özge Gürcanlı Fischer Baum

Yeah, this was a great conversation. I would like to thank all of you, and thanks for joining us at our podcast Under the Cortex.

[00:20:14.640] – William Stoops

Thank you.

[00:20:15.810] – APS’s Özge Gürcanlı Fischer Baum

This is Özge Gürcanlı Fischer Baum with APS. I have been speaking with William Stoops from the University of Kentucky Medical Center, along with his colleagues, Jardin Dogan-Dixon and Danelle Stevens-Watkins from the University of Kentucky, Paris Wheeler from the University of Cincinnati, and Krystal Cunningham from Boston College. If you want to know more about this research, visit psychologicalscience.org. Do you have suggestions or questions for us? Please contact us at [email protected].