Hello I am Miranda Greiner. I am currently studying at the University of Kansas School of Medicine in Kansas City, Kansas. I have taken this opportunity to construct a preliminary research proposal for future Masters work in Scientific Clinical Research. The Scaife program has introduced me to a stronger interest in addiction disorders and I have written a proposal to implement substance use disorder screening in a local free health clinic. This particular free health clinic caters to a majority Hispanic (or Latino) patient population. Instead of discussing methodology – I’d like to present on some interesting points of my background research. Specifically, I will present on factors that predict substance use and abuse prevalence rates among the Latino adult population.
I have chosen to carry out research at the free health clinic JayDoc because student-physicians run this clinic, which allows opportunities for program development by students. JayDoc Clinic is a nonprofit organization led by students and volunteer physicians and provides primary care services to the uninsured and underinsured populations in the Kansas City area. This patient population tends to be majority Hispanic (or Latino). Referrals are made to other clinics in the Safety Net system to ensure ongoing medical care.
Despite the similarity in prevalence rates and chronicity of substance use disorders and non-communicable diseases, there continues to be a lack of effective screening and evaluation for substance use disorders in the general medical clinic setting. Quality medical treatment, especially in the primary care setting, involves comprehensive medical and social evaluations of each patient.
Although there needs to be better screening in all populations, minority groups have less access to care in general and receive sub-optimal health care services, including for substance abuse. For instance, a combined 2004-2008 study by the National Survey of Drug Use and Health 2010 reported an estimated 2.5 million Latino adults (8.7 percent) were classified as being in need of treatment for an alcohol use problem within the past year. While the difference between the rate for Latinos and the national average (8.7 versus 8.1 percent) was relatively small in this study, it was still statistically significant. In general, rates of past month alcohol and illicit drug use for Latinos mirrors the national averages. However the rate of past month binge alcohol use among Latino adults was reported higher than the national average. Co-occurring mood and anxiety disorders were common among substance-abusing Latinos and Latinas in the U.S., as they are among the rest of the population. Women and U.S. born Latinos and Latinas have higher rates of co-morbid mood and anxiety disorders than men and foreign-born individuals. Latinos who were born in the United States had higher rates of past month alcohol use, binge alcohol use, and illicit drug use compared to those who were not born in the United States.
Compared to European Americans, Latinos have less access to substance abuse treatment, wait longer to access these services, and are less satisfied with the services once they do enter treatment. Latinos also have poorer outcomes after substance abuse treatment programs compared to European Americans.
Many studies have supported that sociodemographic variables and a number of indicators of assimilation to U.S. culture can predict rates of substance use and abuse among Latinos.
Latinas are more likely than Latinos to abstain from using alcohol and illicit drugs. But Latinas are less likely to abstain from using alcohol if they are associated with non-Latinos or non-Latinas, used English-speaking media, and hold U.S cultural values.
Studies have also shown that specific cultural values play a role in the process and outcome of substance abuse treatment for Latinos. These do not vary greatly from general cultural values of other populations except maybe the patriarchal role. The Latino gender roles can emphasize the public appearance of patriarchy that greatly stems from past European-originated machismo culture. “Personalismo” refers to an emphasis on interpersonal relationships and “simpatia” refers to downplaying conflict in relationships.
There is a positive relationship between English proficiency and substance use and abuse. For example, national epidemiological studies consistently find that Latinos who choose to be interviewed in English are more likely to use and abuse substances than those who request to be interviewed in Spanish. English might also represent adaptation to U.S. values and norms such that English-speaking Latinos use substances in ways that are similar to the general American population.It is also possible that Spanish-speaking Latinos are more reluctant to report substance use and abuse in response to the community surveys due to fears of lack in confidentiality. Another explanation for higher rates of substance use among English-speaking Latinos involves the loss of connection to family and culture, or to stresses related to minority status among individuals who are committed to becoming part of the mainstream U.S. culture.
TheNational Survey of Drug Use and Health reported that substance use varied greatly by subgroup. Past month illicit drug use, for example, ranged from a high of 13.1 percent among adults of Spanish origin to a low of 3.9 percent among those of Dominican origin. These group differences may reflect the differences in assimilation/adaptation to U.S. culture, among other factors.
As mentioned earlier, Latinos and other immigrants are less likely to use both alcohol and illicit drugs compared toU.S. born individuals.
I really believe that the delivery of culture into treatment services can change patient outcomes with any illness, whether it is diabetes or a substance use disorder. It is important when approaching health care services in any population to understand as much as possible about the cultural background, demographics, and barriers to treatment. And often patients will be the teachers of their cultures, so just listening will guide in individualized treatment plans. This presentation showed a brief view into characteristics of substance use and abuse among the Latino population. But it is also important to note the majority of these facts are based on national surveys. Unfortunately, most large-scale surveys of substance use and abuse have failed to measure indicators of assimilation and most have not controlled for demographic variables in their data analyses. Because of this, I am surveying for indicators of acculturation (by language use, place of birth, and generation in the U.S) and sociodemographic variables with the substance use disorder screening.
Ideally, future aims of this research will help in the design of an integrative model of treatment that addresses four broad domains: (1) the nature and severity of substance use and problems, (2) motivation for change, (3) client strengths and resources, and (4) a functional analysis of substance use. My current research proposal will serve as a preliminary assessment of substance use disorder prevalence rates among an underinsured Latino population. This is the first of many studies that will help in designing a treatment model for the Latino population.
This is a blurry table image that lists different evidence-based sources for screening and multidimensional evaluation from an integrative treatment model by the authors of “Treating Addiction”. Most of these sites link to free materials. I have handouts here if you are interested.
Surveying for Substance Use Disorders in a free Health Clinic Setting
Surveying for Substance UseDisorders among Latinos ina Free Health Clinic SettingA preliminary assessment.Miranda GreinerUniversity of Kansas School of MedicineMaya Health Alliance VolunteerScaife Fellow July 2012
JayDoc Free Health Clinic Jayhawk + Doctor = JayDocNote: I had nothing to do with the creation of this name.
NCDs(Noncommunicable Diseases) Versus SUDs (Substance Use Disorders)
National Survey on Drug Use and Health 2010: Adult Hispanics (Latinos) 2.5 million (8.7%) Latino adults in need of treatment foran alcohol use problem within past year Higher rates of binge alcohol use among Latino adults Higher rates of co-morbid mood and anxiety disorder inwomen and U.S.-born Latinos/as Higher rates of past month alcohol use, binge alcoholuse, and illicit drug use compared to those not born in theU.S.
Substance Use Disorder Treatment in Hispanic (Latino) Population Less access to care Wait longer to access SUD services Unsatisfied with SUD services once they do enter treatment Poorer outcomes after substance abuse treatment compared to European Americans
Variables that Predict Rates of Substance Use and Abuse among Latinos Gender differences Cultural values Language Heterogeneity in Latino groups Place of birth
Gender Differences Latinas are more likely to abstain from alcohol and illicitdrugs compared to Latinos. Latinas are less likely to abstain from alcohol if theyassociate more with U.S. cultural values.
Cultural Values Dignity and respect Spirituality and religion Family support “Personalismo” “Simpatia” Gender roles (patriarchy)
Relationship between English Proficiency and Substance Use and Abuse Adaptation to U.S. values with English proficiency Spanish-speakers reluctant to report substance use andabuse in surveys Loss of connection to family and culture with Englishproficiency Stresses related to minority status among individualsseeking acceptance in U.S. culture
Nature and Severity of Substance Use and ProblemsFunctional Integrative MotivationAnalysis of Treatment forSubstance Model Change Use Client Strengths and Resources
ReferencesADA (American Diabetes Association). Jan. 2011. [www.diabetes.org]Alvarez, J., Jason, L. A., Olson, B. D., Ferrari, J. R., & Davis, M. (2007). Substance abuse prevalence and treatment amongLatinos and Latinas. Journal Ethnic Substance Abuse, 6(2): 115-141.Amaro, H., Cortés, D., & Cacari-Stone, L. Improving Research on Hispanic Drug Abuse: Key Strategies for Policy Makers.Amaro H., Whitaker, R., Coffman, G., Hereen, T. (1990). Acculturation and marijuana and cocaine use: Findings from H-HANES 1982-1984. American Journal of Public Health, 80; 54-60 [PubMed: 9187583].Black, S., Markides, K. (1993). Acculturation and alcohol consumption in Puerto Rican, Cuban American, and Mexican-American women in the United States. American Journal of Public Health, 83; 890-893 [PubMed: 8498630].Burrow-Sanchez, J., Martinez, C., Hops, H., & Wrona, M. (2011). Cultural accommodation of substance abuse treatment forLatino adolescents. Journal Ethnic Substance Abuse, 10(3): 202-225.Caetano, R. (1993). Ethnic minority groups and alcoholic anonymous: A review. In: McGrady, B. S.; Miller, W. R., editors.Research on Alcoholics Anonymous: Opportunities and Alternatives. New Brunswick, NJ: Rutgers Center on Alcohol Studies; 209-231.Caetano, R. (1994). Drinking and alcohol related-problems among minority women. Alcohol Health and Research World, 16; 233-241.Caetano, R. (1994). Drinking and alcohol related-problems among minority women. Alcohol Health and Research World, 16; 233-241.Caetano, R., & Clark, C. (1998). Trends in alcohol-related problems among Whites, Black and Hispanics: 1984 – 1995.Alcoholism: Clinical and Experimental Research, 22; 534-538.Caetano, R., Ramisetty-Mikler, S., & McGrath, C. (2004). Acculturation, drinking, and intimate partner violence amongHispanic couples in the United States: A longitudinal study. Hispanic Journal of Behavioral Sciences, 26; 60-78.
References continuedDovidio, J. F. & Fiske, S. T. Under the radar: how unexamined biases in decision-making processes can contribute to healthcare disparities. May 2012. American Journal of Public Health. Vol 102. No. 5. 945-952.Flores, Victor. Cultural Elements in Treating Hispanic/Latino Populations. August 2011. Caribbean Basin and Hispanic ATTC:Unifying science, education, and services to transform lives.Hernandez, L., Eaton, C, Fairlie, A., Chun, T., &Spirito, A. (2010). Ethnic group differences in substance use, depression, peerrelationships and parenting among adolescents receiving brief alcohol counseling. Journal Ethnic Substance Abuse; 9(1): 14-27.Hispanic Workgroup at NIDA (National Institute on Drug Abuse) [http://www.drugabuse.gov/]Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangus, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of GeneralPsychiatry, 62, 593-602.Lee, C. S., López, S., Hernández, L., Colby, S., Caetano, R., Borrelli, B., & Rohsenow, D. (July 2012). A cultural adaptation ofmotivational interviewing to address heavy drinking among Hispanics. Cultur Divers Ethnic Minor Psychol. 2011 July, 17(3):317-324.Miller, William R., Forceheimes, Alyssa A., & Zweben, Allen. (2011). Treating Addiction: A Guide for Professionals. TheGuilford Press, New York, NY.Moyers, T. B., & Miller, W. R. (1993). Therapists’ conceptualizations of alcoholism: Measurement and Implications forTreatment. Psychology of Addictive Behaviors, 7, 238-245.National Hispanic Science Network [http://www.nhsn.med.miami.edu]Rosa, M., Babino, R., Rosario, A., Martinez, N., & Aijaz, L. (2011). Challenges and strategies in recruiting, interviewing, andretaining recent Latino immigrants in substance abuse and HIV epidemiologic studies. The American Journal of onAddictions, 21: 11-22.
References continuedSAMHSA Screening, Brief Intervention, Referral to Treatment [SBIRT]. [http://www.samhsa.gov/prevention/sbirt/]Schinke, S., Moncher, M., Palleja, J., Zayas, L., & Schilling, R. (1988). Hispanic youth, substance abuse, and stress:implications for prevention research. Int J Addict, 23(8): 809-826.Schomerus, G., Corrigan, P.W., Klauer, T., Kuwert, P., Freberge, H. J., & Lucht, M. (2011). Self-stigma in alcoholdependence: Consequences for drinking-refusal self-efficacy. Drug and Alcohol Dependence, 114(1), 12-17.Schomerus, G., Lucht, M., Holzinger, A., Matschinger, H., Carta, M. G., & Angermeyer, M. C. (2011). The stigma ofalcohol dependence compared with other mental disorders: A review of population studies. Alcohol & Alcoholism, 46(2),105-112.Substance use among Hispanic adults. National Survey on Drug Use and Health. SAMHSA (June 2010).Szapocznik, J., Prado, G., Burlew, A. K., Williams, R., & Santisteban, D. (2007). Drug abuse in African American andHispanic adolescents: culture, development, and behavior. Annual Review of Clinical Psychology, 3: 77-105.Unger, J. B., Ritt-Olson, A., Wagner, K. D., Soto, D.W., & Baezconde-Garbanati. Parent-child acculturation patterns andsubstance use among Hispanic adolescents: a longitudinal analysis. (2009). Journal of Primary Prevention, 30: 293-313.Unger, J. B., Ritt-Olson, A., Soto, D. W., & Baezconde-Garbanati. (2007). Parent-child acculturation discrepancies as a riskfactor for substance use among Hispanic adolescents in Southern California. Journal of Immigrant Minority Health, 11: 149-157.
AcknowledgementsThank You to the IRETA staff, theScaife Foundation, and allpresenters who contributed to thisprogram. I especially thank eachone of you for installing spirit intothe field of treating addictions.