Table of Contents
RACIAL DISPARITIES IN SUD TREATMENT FOR WOMEN
CULTURALLY RESPONSIVE DESIGN PROCESS
Family-Focused Recovery Model Definitions
FFR: General reference to the FFR program and its recovery services, and states with existing FFR programs that do not currently reflect the envisioned “model” program.
VOA: Volunteers of America is the national non-profit that operates thousands of human services, housing, and healthcare programs, including Family Focused Recovery for pregnant and parenting women with substance use disorder.
Contributors: M William Sermons, PhD.; Todd D. Molfenter, Ph.D.; Margaret Ratcliff; Barbara Banaszynski; Abbie Gilbert
ASAM: American Society of Addiction
SUD/OUD: Substance/opioid use disorder
Published January 2023
INTRODUCTION
Women and their children are increasingly impacted by Substance Use Disorders (SUD), and accessible and equitable treatment programs that integrate comprehensive services for both women and children are sorely needed. Treatment programs that combine SUD treatment where parents and children remain together, along with prenatal care, parenting, and children’s services, are effectively helping families reduce substance use and improve children’s health and safety (Werner et al, 2007).
Volunteers of America (VOA), a national non-profit, is one of the organizations that has been producing positive results for pregnant and parenting women and their children for over 25 years. The VOA Family Focused Recovery (FFR) model is gender-specific, trauma-informed, and uses evidence-based practices. It focuses on family unity; offers comprehensive ASAM-certified treatment, including intensive residential treatment, intensive outpatient, and medication-assisted treatment (MAT); transitional housing and peer support; parenting education and therapeutic supports for children; and coordination of maternal and children’s health services.
Despite the urgent need for such services, and evidence of their effectiveness, the number of comprehensive SUD treatment and recovery programs for women with their children is inadequate. There are too few comprehensive programs for mothers with their children, making recovery services inaccessible to many families. Funding is a major barrier to new programs since fee-for-service Medicaid only partially covers operations, leaving programs scrambling for government grants and philanthropy.
VOA has committed to increasing access by opening more programs in additional states. VOA has documented its FFR program model in a replication handbook to help guide the development of new VOA FFR programs. VOA is addressing the funding challenge through a collaboration with Humana and Quantified Ventures, an outcomes-based capital firm, which is a novel financing approach that pairs value-based purchasing (VBP) with outcomes-based financing. (Accelerating Family Access to Substance Use Disorder Recovery Programs through Innovative Financing and Partnership). VOA is using this innovative financing approach, along with community collaboration and advocacy in Southeastern Kentucky, an underserved rural region at the epicenter of the opioid crisis. Expansion into several additional states is planned.
As VOA accelerates access to family recovery services by adding programs in new geographies, the VOA FFR model cannot simply be replicated in a cookie-cutter manner. The community, its culture, and its people must be considered through a health equity lens. The expansion in Southeastern Kentucky demonstrates how rural health equity can be addressed by opening family treatment and recovery services, along with a recovery court, recovery community center, and employment opportunities, which are reducing health disparities. By listening to and employing women from the community, especially those with lived experience, the treatment model is being shaped by the community.
When VOA opens family recovery services in new states and cities, health disparities in family recovery services will be anticipated so that the program can focus on reducing barriers to equitable care. VOA will use culturally responsive design to shape the FFR model for and with the communities. The approach will be piloted in New Orleans, where a new FFR Program is being developed. This paper lays out VOA’s plans to address racial equity in the design and development of the New Orleans family recovery program.
The paper:
- Explores racial disparities in SUD treatment for pregnant and parenting women
- Profiles New Orleans
- Presents plans to pilot a culturally responsive design process in New Orleans
By listening to and employing women from the community, especially those with lived experience, the treatment model is being shaped by the community.
Racial Disparities in SUD Treatment for Women
To anticipate racial disparities that may be experienced as SUD services are developed in New Orleans, a Black-majority city, literature on racial disparities in SUD treatment for women and those who are pregnant or parenting was explored. A small but growing body of research revealed very similar levels of need for treatment among African American women and non-Hispanic White women, but very different treatment experiences. Lower levels of entry into treatment by African American women are compounded by lower levels of success in treatment to create important disparities.
Low Treatment Utilization
One particularly relevant study documented the demographic characteristics of women utilizing a nonprofit treatment facility for women in New Orleans. The authors of that study concluded that despite the need for substance use disorder treatment in the majority-Black city, young African American women were “virtually absent” from the New Orleans facility (Hopper et al., 2021).
The experience in New Orleans is not a geographically isolated pattern. Analysis of the National Survey on Drug Use and Health (NSDUH) by the Center for Behavioral Health Statistics and Quality (2021) reveals a common pattern across the nation. The accompanying data set shows patterns of past-year illicit drug use (including misuse of prescription drugs), substance use disorder, and treatment utilization among those needing treatment for women by race.
Substance Use, Substance Use Disorder, and Treatment Utilization by Race
The data reveal that African American women across the US have very similar patterns of illicit drug use as non-Hispanic White women as well as similar levels of substance use disorder. The data also reveal that while the large majority of women of all races who need substance use disorder treatment fail to receive treatment, utilization is particularly low for African American women needing treatment (CBHSQ, 2021)
Barriers to Treatment Success
While simply making it into treatment is a big hurdle for African American women, they face a litany of challenges to achieving recovery through those programs:
- Late arrival to treatment. Montgomery et al (2019) show that African Americans enter treatment at an advanced stage of addiction, which complicates their path to successful recovery.
- Challenges with specific program elements. For example, a study conducted in Massachusetts found African American and Hispanic women are significantly less likely to consistently use medications than non-Hispanic Whites in opioid use disorder treatment (Schiff et al., 2020).
- Lower completion rates. Saloner & Lê Cook (2013) and others (Mennis J, Stahler GJ, 2016) find that African Americans and Hispanics are less likely than NH Whites to complete SUD treatment.
- System challenges. Several systems and institutions involved in the lives of pregnant and post-partum women influence entry to treatment and completion. As such, research has shown that African Americans were more likely to have their treatment terminated by a treatment facility (Ortega, 2022). Stigma associated with SUD for pregnant and postpartum women can lead to child welfare involvement and the suspension of treatment services. (Wilson et al., 2021). As of 2019, almost 40% of child removal cases were due to parental AUD and SUD (Children’s Bureau, 2019). A plurality of referrals for SUD treatment come from the criminal justice system. While criminal justice system referrals have the highest completion rates, referred NH Whites have higher completion rates than African Americans (Sahker et al., 2015)
- Poorer outcomes. Analysis of federal data on treatment episodes revealed that African Americans were less likely to reduce substance use than non-Hispanic Whites after treatment (Sahker E, Sakata, and Furukawa, 2016).
Collectively, these challenges lead to disparate outcomes for African American women with substance use disorders.
LOUISIANA
PROFILE | NEW ORLEANS
The authors call for “genuine, impactful changes to how substance use treatment is accessed by all minority groups, but especially Black women.”
NEW ORLEANS, LA.
New Orleans is home to almost 400,000 people, 60% of whom are Black. Louisiana is a poor state that lacks adequate resources for its children and families; its overall poverty rate ranks second nationally, as does its Child Poverty rate with 30% of children in New Orleans living in poverty. Racial disparities in income, housing, health, education, and criminal justice involvement abound. For example, median incomes for Black households were less than half that of white households, Black mothers were 2.5 times as likely to have a low birth weight baby as white mothers, 3 times as many white adults complete college degrees than Black adults and Black people were overrepresented in jail at a rate of 4.6 compared to white. (Office of Criminal Justice Coordination, 2021).
New Orleans suffers from the impact of opioid and other illegal drugs. However, where New Orleans is especially vulnerable is in the lack of access to quality SUD treatment, especially facilities that allow the family unit to remain intact, as well as equity in access to treatment across racial lines. The New Orleans Region has no comprehensive family-focused SUD treatment programs for women with their children. In 2019 there were 363 Residential Addictions Treatment Programs for Women with their Children, spread across 48 states and the District of Columbia and Puerto Rico. Louisiana previously had 8 residential treatment programs for women with their children, and three of those programs were in New Orleans. Today, there are only three programs remaining in Louisiana, and none in the New Orleans Region. Insufficient funding is blamed for the program closures. These closures are happening at the same time that untreated drug use is having a devastating impact on women and newborns. In addition to over 300 NAS births in 2020, Louisiana’s high rates of preterm newborns may be partially attributable to drugs. Drug overdoses are now a leading cause of pregnancy-associated deaths in the state VOA will tackle the issue of cultural responsiveness and racial disparities head-on. Racial disparities in access, completion of SUD treatment, and outcomes are widely reported in the literature. Of particular relevance to this project, racial disparities in a New Orleans residential substance use program for women were documented in a recent study. The study found that 78% of women admitted to the program are white, and 15% are Black. Since New Orleans’s population is 60% Black, the disparities were evident. The authors call for “genuine, impactful changes to how substance use treatment is accessed by all minority groups, but especially Black women.”
30%
of all New Orleans children live in poverty
VOA Health Equity Framework
Health equity means everyone has a fair and just opportunity to be as healthy as possible. In 2022, VOA adopted the VOA Health Equity Framework to serve as an organizational roadmap for pursuing the vision of a world where all people experience social, emotional, and physical well-being. In pursuit of this vision, the framework asserts that VOA will reach and improve outcomes among populations experiencing inequities by delivering programs and services that are inclusive, culturally relevant, and responsive to community needs.
SHARED POWER & DECISION-MAKING
Engage affiliates, community partners, and clients in defining the problems, developing solutions, and determining success.
LEADERSHIP & WORKFORCE
Transform our leadership and workforce into diverse, culturally competent, equipped, and empowered to advance health equity. Provide equitable access to opportunities for professional development and career advancement.
FUNDING
Invest and secure resources according to need, incorporate health equity requirements, and allow flexibility to address community priorities.
PROGRAMS & SERVICES
Reach and improve outcomes among populations experiencing inequities by delivering programs and services that are inclusive, and culturally relevant. and responsive to client and community needs.
ADVOCACY & COMMUNICATION
Share health equity efforts and insights with affiliates, community partners, and the broader health and social service fields; amplify lived experience; and advocate for policies that increase access to care and advance equity.
MONITORING & EVALUATION
Gather and analyze disaggregated and qualitative data to identify inequities, clarify barriers to care, and improve programs and services.
ACCOUNTABILITY
Set SMART health equity goals and prioritize and implement strategies to achieve them: monitor and report progress.
The AIMM Approach
An essential component to putting the framework into action is the AIMM Approach. The “A” in AIMM stands for strategies that assess strengths and opportunities for improvement. The “I” stands for intervention strategies. And “M” is for strategies related to monitoring and maintaining progress. The AIMM approach also highlights the importance of applying the overarching principles of shared power & decision-making and accountability as VOA moves from the health equity framework to strategic planning to action. The AIMM objectives will be met through a culturally responsive design process that is specific to the SUD treatment context.
Culturally Responsive Design Process
The VOA treatment model will be customized for cultural responsiveness and racial equity using the evidence-based NIATx Co-Production technique. New Orleans is a Black-majority city, and racial disparities have been identified in an existing residential SUD treatment program for women. Since the VOA model was developed in white-majority areas, this customization is an important step. The technique has been evaluated in a nationwide randomized trial of over 200 addiction treatment agencies (one of the largest randomized trials of organizational change strategies ever conducted). It is also distinguished by its simplicity, based on five key principles: rapid cycle testing, deep understanding of the customers of the improvement effort, commitment to engagement of senior leaders, the appointment of a highly respected team leader, and reaching outside the boundaries of the industry for improvement ideas. It focuses on measuring a small number of items rather than a broad collection of data that is only indirectly relevant. It is also distinguished by the use of innovative tools such as the nominal group technique for setting priorities in a way that builds support from multiple individuals and organizations. The approach has been employed in over 3500 addiction treatment agencies and has demonstrated a lasting impact.
The Co-Production Planning will be centered around a Community Policy Planning Board that will include community stakeholders who are opinion leaders in the Black community, as well as representation from key referral sources, local individuals with lived experience, and VOA representatives. This limited-term board’s purpose will be to establish the most pressing needs for pregnant and postpartum Black women with SUDs and their insights into how VOA can most effectively meet these needs. The work of the Board will be complemented by three Community Co-Production Events where Black mothers with lived experience can describe and prioritize SUD treatment needs, using the nominal group technique, and how these services can be designed to be culturally responsive. The optimal program operational features generated by the board and the Community Co-Production Events will be integrated into a Patient Mapping Exercise that will determine structural, workflow, and clinical features the New Orleans program will apply to attract and retain Black pregnant and parenting women.
Conclusion
VOA is designing an enhanced and equitable substance use treatment model for women with their children for 2023 implementation in New Orleans. Building on VOA’s 25 years of experience providing SUD treatment for mothers with their children, the VOA FFR model will be customized for New Orleans, applying a racial equity lens. Using the evidence-based NIATx process, a culturally responsive program will be co-created with the community. VOA will learn from the New Orleans experience, refine the design process for future programs, and use the process to create treatment programs in future locations that are inclusive, equitable, culturally relevant, and responsive to the communities.
However, a culturally responsive program model is not enough unless systems and institutional barriers are also addressed. Diversion of women with their children to treatment should be standard practice, rather than incarceration and/or child removal. The pandemic, rising overdose rates, the opioid epidemic and the increasing criminalization of SUD usage provide an unprecedented opportunity for community treatment advocates and leaders to address addiction policy, criminalization, and systemic institutional bias that has led to inequities and disparities in access to appropriate culturally sensitive treatment for pregnant and parenting women, especially African American and Hispanic women. An encouraging step in this direction for New Orleans is VOA’s new partnership with the state child welfare agency, Orleans Parish Juvenile Court, the state behavioral health agency, and other collaborators who are joining together to reduce out-of-home placement of infants and children as a result of their parent’s substance use.
Success will be measured not only by increasing family access to comprehensive SUD treatment and reducing disparities in treatment by aligning programs to the local culture but also by continuous engagement with recognized community leaders, church leaders, community advocates, and peer-led groups. Working with the community and its leaders offers the best path forward to changing addiction policy and the long-standing systemic discriminatory factors and reducing the criminalization of addiction.
