Diversity Issues in Substance Abuse Treatment and Research

Transcription

1 Diversity Issues in Substance Abuse Treatment and Research

2 Diversity Issues in Substance Abuse Treatment and Research Sana Loue Case Western Reserve University Cleveland, Ohio KLUWER ACADEMIC PUBLISHERS NEW YORK, BOSTON, DORDRECHT, LONDON, MOSCOW

3 ebook ISBN: Print ISBN: Kluwer Academic Publishers New York, Boston, Dordrecht, London, Moscow Print 2003 Kluwer Academic/Plenum Publishers New York All rights reserved No part of this ebook may be reproduced or transmitted in any form or by any means, electronic, mechanical, recording, or otherwise, without written consent from the Publisher Created in the United States of America Visit Kluwer Online at: and Kluwer's ebookstore at:

4 Preface Although the term diversity is widely used, there is often no agreement as to its meaning or how attention to diversity should be operationalized within the context of programming or research. This text provides a foundation for the examination of such issues, with suggestions for the integration of various approaches into substance use treatment programs and research. The impetus for this work derived from multiple interactions over a period of several years with colleagues, students, research participants, and community-based providers, who noted the frequent inattention paid to such concerns in the context of treatment and research, often despite an acknowledgment of a group s particular historical legacy in the United States and the impact of that history on the initiation and prolongation of substance use within a specified community, or the barriers to treatment that may have resulted. Chapter 1 defines what is meant by diversity through an examination of related terms, such as culture, ethnicity race, sex, gender, and sexual orientation. Clearly, this discussion does not and cannot reflect all possible permutations of human existence that reflect diversity. For instance, although the text does make mention of considerations related to religious differences and cognitive capacity, neither is highlighted as a separate topic. Additionally, the emphasis on specified groups is not meant to imply that other groups, such as Euro-Americans or heterosexual men, do not have concerns that may differ from those of other communities and that deserve consideration in the development and implementation of programs and research endeavors. However trite it may seem, one text cannot do it all. Chapter 2 begins with an examination of the concepts of addiction and dependence and continues with a review of what we know today about v

5 vi Preface the effects of alcohol, tobacco, marijuana, cocaine and crack, hallucinogens, and heroin. These particular substances were selected for discussion for several reasons. First, each substance mentioned is now or has been legal for general use during some period of time in United States history. Second, this listing reflects the position of these drugs along a spectrum of legality, ranging from alcohol and tobacco, which are legally available with some restrictions; to marijuana, whose legality varies depending on the locale; to cocaine and heroin, which are currently illegal for use. Chapter 3 focuses on the development of policy over time with respect to each of these substances, with special emphasis on the relationship of that policy to the attributed characteristics of the groups who were perceived to be the most fervent users of the substances. The characterization of behavior as substance use or dependence, or of an individual as being dependent, and our approach to that condition are necessarily a function of various assumptions and decisions: our definitions of substance use and dependence; our choices regarding the (il)legality of specified substances; and our perceptions of the cause(s) of this condition, the individuals believed to reflect the condition at issue, and the appropriateness of various responses to both the causes and the individuals. One writer has explained: Both miracle or dangerous drugs are made, not born, and borne largely from cultural and political circumstances. A teleological or Whig view of drug control regimes that they progressively emerged as we became enlightened about the relative health risks of certain substances is unrealistic. Chemistry and biology are at work, but make risky guides for deducing drug history and its moral outcomes. Definitions of harm to individuals or societies are rarely resolved in the pharmacocentric or medical sphere, as testified by our current cultural struggles to reassess (or even invert) the roles of tobacco and marijuana. Drugs are protean and relational things, and cultural magnets for charged meanings. The line between today s licit and socially ingrained drugs and taboo ones was historically drawn. Clearly, constructionist perspectives are apt for looking at transformations in the status of drugs and at the erection of control regimes (Gootenberg, 1999: 7). Chapters 4 and 5 focus on the history of specified groups in the United States and the relationship of that history to substance use, access to care, and health issues related to substance use. These groups include African- Americans, Asians and Pacific Islanders, Hispanics/Latinos, and various communities defined by sex, gender, and/or sexual orientation. Chapters 6 and 7 provide guidelines for the integration of diversity considerations into treatment programs for and research procedures with these communities.

6 Acknowledgments The impetus for this work derived from multiple interactions with colleagues, students, research participants, and community-based providers over a period of several years. These individuals are too numerous to mention but, nevertheless, deserve to be recognized for their insightful comments relating to diversity and the lack of attention to such issues in the context of treatment and research. Several people deserve special mention for their assistance with the development of this text. Nancy Mendez, a student and a colleague, provided me with invaluable feedback on earlier drafts of this book. Gary Edmunds, Jenice Contreras, and Ingrid Vargas provided me with invaluable research assistance. Mariclaire Cloutier of Kluwer Academic deserves accolades, as always, for her editorial support and encouragement. vii

7 Contents Introduction... 1 Chapter 1. Diversity: Theory and Meaning... 1 Diversity Defined... 2 Constructing Diversity... 4 Theories of Individual and Collective Identity Construction... 4 Diversity and the Construction of Racial and Ethnic Identities... 6 Diversity in Sex, Gender, and Sexual Orientation Barriers to Addressing Difference Chapter 2. Substance Abuse and Dependence: Definition, Causation, Epidemiology, and Sequelae Defining Addiction The Epidemiology of Addiction Theories of Causation The Neurobiology of Addiction The Genetic Contribution to Addiction Psychosocial Factors Associated with Substance Use Contextual Factors and Substance Use Drugs: Usage and Outcomes The Impact of Alcohol The Impact of Tobacco The Impact of Marijuana The Impact of Cocaine and Crack The Impact of Hallucinogens The Impact of Heroin ix

8 x Contents Chapter 3. The Development of Drug Policy Alcohol: Use, Abuse, and Policy Practice, Perception, and Politics: The Interplay The Economics of Alcohol Use, Abuse, and Dependence Tobacco: Use, Abuse, and Policy The Beginnings Regulatory Efforts Marijuana: Use, Abuse, and Policy Practice, Perceptions, and Politics The Initiation of Drug Regulations The Economics of Marijuana Use, Abuse, and Dependence Cocaine and Crack: Use, Abuse, and Policy The Medical Era of Cocaine Use The Popular Era of Cocaine Use The Age of Crack Hallucinogens: Use, Abuse, and Policy Heroin, Use, Abuse, and Policy Practice, Perception, and Politics The Economic Impact of Heroin Current Policies and Policy Options: Punish or Treat? Prison and Prison-Based Treatment Civil Commitment Drug Courts Harm Reduction Chapter 4. Considering the Historical and Cultural Context: Race and Ethnicity African-Americans: Historical and Cultural Context The Historical Context Substance Use and Health Asians and Pacific Islanders: Historical and Cultural Context The Cultural and Historical Context Substance Use and Health Hispanic Communities in the United States: Historical and Cultural Context The Cultural Context The Historical Context Substance Use and Health Native Americans: Historical and Cultural Context Origin and Culture Areas Current Demographics The Cultural Context

9 Contents xi The Historical Context Substance Use and Health Chapter 5. Considering the Historical and Cultural Context: Sex and Sexual Orientation Women Cultural and Historical Context: Sex and Gender Substance Use and Health Queer Communities Cultural and Historical Context Substance Use and Health Chapter 6. Diversity Issues in Treatment Integrating Diversity into Treatment: General Considerations Diversity and Service Delivery Involving Community Barriers to Treatment Documentation of Need Lack of Culturally Specific Models of Treatment Legal Risks Developing Culture-Centric Approaches African-American Communities Asian and Pacific Islander Communities Hispanic/Latino Communities Immigrant Communities Native American Communities Women Queer Communities Chapter 7. Diversity Issues in Addiction and Treatment Research Integrating Diversity Issues in Research: General Considerations Barriers to Recruitment History and Its Legacy Stigmatization, Ostracism, and Violence Economic Factors Legal Difficulties Developing Culture-Centric Approaches Tailoring the Recruitment Efforts Reducing Risks of Participation References Index