Intersectionality and Addressing Disparities

Introductory Paragraph

This is the second in a pair of related articles on health equity centered around disparities and disproportionality. The first article titled, “Apply a Health Equity Lens,” focused on resources associated with building health equity. This requires an active commitment to remove obstacles for groups that are more impacted by inequity. The material below centers on strategies in the field of substance use which are associated with populations impacted by various systemic inequities.

Key Information

Addressing disparities begins by acknowledging that we are all unique and hold multiple identity lenses. Likewise, as members of different groups within our communities, we experience thesse differences in navigating screening, diagnosis, treatment, and recovery supports. This is particularly relevant in the historical context of substance use because some groups have been more marginalized or historically underrepresented and impacted by systemtic inequities over others. For example, recent overall statistics demonostrate a 14.5% decline in national overdose deaths for the 12-month period ending June 2024. However, upon further examination, it becomes apparent that the recent decrease in the overdose rate is not uniformly distributed. Positive trends predominantly benefit White people.

Increased awareness of disparities and disproportionalities impacts the way communities can address substance use in relation to the specific needs of youth, military-connected families, LGBTQI+ individuals, people with disabilities, those with lower socio-economic status, and pregnant people. The Drug Policy Alliance reports that the US has lost over one million lives to drug overdose during this recent crisis — yet, even though people of all races and ethnicities use drugs at similar rates, racial and ethnic disparities are evident:

• While studies show that Black people use cocaine at similar rates to other racial and ethnic groups, the overdose rates related to cocaine for Black individuals, disproportionately higher compared to White individuals. Clear racial differentials exist in access to harm reduction programs and medicated-assisted treatment/recovery (MAT/MAR).
• The overdose rate for Native Americans, between 2021 and 2022, increased by 15% while they decreased for Whites. While national overdose rates in 2020 were comparable for Whites and Native Americans, most recent data reflect Native American rates are almost double the rate for Whites. Some of this difference is attributable to limited resources on tribal lands. A large component is associated with variability in overdose interventions are associated with methamphetamines, versus opioids. In 2022, the national Native American overdose fatality rate associated with methamphetamines was more than double the rate for Whites. Tribal lands often have limited infrastructure impacting service delivery. Oftentimes, resources off reservations can be a transportation barrier and lack cultural competency to effectively serve Native Americans.
• Latinx communities have experienced significant challenges with rising overdose rates (doubling between 2018 and 2022), especially as the prevalence of Fentanyl has increased. This is compounded by barriers to care, such as language access and documentation status.
• Linguistic disparities affect a large portion of the approximately 26 million people who have limited English proficiency (LEP). One survey found that adults with LEP report worse health status and increased barriers in accessing health care compared to English-proficient adults. One out of three say they have faced language barriers when seeking health care. Twice as many LEP adults than English-proficient adults report not having a usual source of healthcare and almost twice as many report having fair or poor health.

Inequitable impacts are also well documented across the following identities:

• Socioeconomic Status (SES). In a summary of research within NIH funded by the National Institute on Minority Health and Health Disparities (NIMHD), two “pillars of health disparity science” were identified. The first encompasses the racial and ethnic disparities described above. The second pillar relates to SES which “contributes to health disparities through limited resources and opportunities to engage in health-promoting activities relative to high educational attainment and income.” Lower SES was found to be strongly linked with health outcomes, including mortality. More specifically related to SUD disparities, SAMHSA data indicates that in 2019 the uninsured populations had a 7.3% rate of alcohol use disorder compared to a 5.0% rate for the insured.

• Geographic Disparities. The Rural Health Information Hub documents higher rates of binge drinking in rural areas as well as use of tobacco, methamphetamines, and opioids. Challenges faced in rural communities include lower number of behavioral health and detoxification services and a decreased range of services in centers which can be accessed. Greater distance to substance use disorder treatment often results in lower completion rates of substance use treatment programs. This is compounded by a differential among rural health providers in a negative perception of treatment for substance use disorder.

• A majority of pregnant people who use substances who do receive appropriate prenatal care and intervention are typically older and White with private health insurance. These people are less likely to be reported to social services, creating significant disparities. People who use substances while pregnant have a great fear of criminalization and mistrust of medical and treatment providers because of the risk of reporting, prosecution, and infant displacement. Those who are disproportionately impacted by social and health disparites, and do seek treatment, often face significant barriers, as their honesty around their circumstances often leads to criminal reporting or an inability to find available and affordable treatment programs that meet their specific needs. See SAFE Solution article titled, "Expand Perinatal Treatment and Support for People with SUDs" for more information.

• Older Adults. An evaluation by the Office of Disease Prevention and Health Promotion within US-HHS on the social determinants of health lists several factors which amplify health disparities for older adults. These include increased isolation for singles aged 65+ as well as decreased ease of access to services and increased need for services, particularly associated with a higher rate of chronic health conditions. In 2020, consumers aged 65 and older averaged out-of-pocket health care expenditures of $6,668, and older Americans spent 14% of their total expenditures on health, compared to 8.4% among all consumers. This forces difficult choices in prioritizing health needs within families which might delay or eliminate pursuit of SUD services.

• Youth. Risk factors for youth(18-25) having higher substance use rates than adults over 25 years old are commonly recognized. For example 2023 data indicate that 18% of youth had a drug use disorder in the past year, compared to 8.6% for adults 26 or older — more than twice the rate. The disparities that youth face in protective factors is less understood. For example, access to alternatives to substance-free activities is based on a variety of social determinants, such as transportation to extracurricular activities and family or community funding to foster equitable access to athletic, artistic, or social functions that promote protective factors such as self-esteem and pro-social bonding.

• Veterans. One in five veterans experience behavioral health problems and veterans are twice as likely to die from overdose than non-veterans. In terms of social determinants of health, one research meta-analysis concluded that “veterans enrolled in VHA services are more medically complex, have lower physical and mental health functioning, and have lower socioeconomic resources, as compared with either non-Veterans or Veterans not engaged in VHA care.”

• Persons with disabilities are 2-4 times more likely to experience alcohol and substance use disorder.

Intersectionality

Intersectionality is a complex topic that warrants a full understanding by anyone engaged in social change work. Intersectionality runs deeper than, and should not be confused with, the type of inter-sectoral work found in promoting environmental justice by both environmentalists and social justice activists. Intersectionality describes a method for defining the mix of social identities with more accuracy than single identity formulations allow. For example, everyone is a blend of gender, race, class, and ability categories as opposed to being a type of member in different categories. Intersectionality has become associated with social and political correlations with privilege and marginalization. The term, intersectionality, was coined by Kimberlé Williams Crenshaw in three legal cases in 1989. Although each of the cases were lost, her position has been adopted widely in the social justice community and is often linked with its formative roots in Critical Race Theory. Crenshaw made a case in law suits for black women that this newly defined form of discrimination transcended racial and gender discrimination because black women were being judged in the legal system separately both as women and as members of a minority rather than as black women. In the decades since, the term has become politically controversial, because it has moved outside of the generally agreed upon descriptive nature of discriminatory patterns to a prescriptive call to action to address sources of structural power differentials. It has been critiqued both for the scope of change for which intersectional advocates calls and for the difficulty in measuring success in conditions which are inherently multi-variable.

Coalition Responsibilities When Addressing Disparities

Coalitions have a responsibility to work towards the well-being and protection of all individuals in our communities, ensuring equity and inclusion in all efforts. The first step in implementing this responsibility is to recognize that history points to long-term patterns of inequity. The next step is to realize the scope and diversity within health inequity. This includes incorporating people with lived experience in the decision making process and implementing trauma-informed approaches. Specific recommendations for practicing cultural competence and humility and for applying a health equity lens in strategy planning are detailed in the section titled “Building Capacity for Health Equity” within the SAFE Solution article on Health Equity.

In addition to the statistics on racial and ethnic disparities detailed above, there are several constituencies within communities for which substance use statistics are less documented. For example, collection of data on the transgender and people questioning their gender identity have been more difficult to collect, particularly for youth, as compared to their heterosexual peers. However, limited data have been collected by SAMHSA in its annual surveys on people who identify as lesbian, gay, or bisexual. Factors around discrimination, trauma, stigma, and lack of services available to meet their needs often double or triple use rates by LGB respondents, for all substances. When a coalition examines the membership of its community, it should look at not only the specific needs of racial, ethnic, and LGBTQ+ communities, but also evaluate the concerns of military-connected people, individuals with disabilities, and those with lower socio-economic status.

One example might help to humanize what may seem to be abstract demographic characteristics. This points to the complexity of systems which are faced in one specific case. Someone named Chris has just been released from prison and is returning home. Chris is fortunate enough to have been supported in developing a recovery plan which includes medication-assisted treatment/recovery (MAT/MAR). However, Chris’s parole officer maintains that Chris cannot use any substances, MAT/MAR, or otherwise. Instead Chris is required to do x, y, and z, none of which are in the recovery plan. A lack of re-entry services and laws in Chris’s state precluded applying for Medicaid in advance. Chris left jail with three days of medication, but cannot see a doctor for a week. Chris is unable to find recovery housing with nearby transportation who will accept someone with a criminal background, so has not yet found employment. Without a job and without prescription coverage, Chris cannot afford to get more medication. The doctor wants to prescribe medications which the parole officer will not allow. If coalition members understand how their local systems are not working together and are working against people, then they can begin to see how difficult daily life might be for undocumented people or LGBTQ+ youth who are ready but uncertain as to how to access substance use services.

Relevant Research

• This article addresses disparities in treatment and access to treatment, regarding economic status and race/ethnicity.

• The Boston University Center for Antiracist Research is a collaborative research and education effort which includes Racial Data Lab, a national online database of racial inequality, and a qualitative (narrative) archive.

• O'Neill Institute for National and Global Health Law published "The Context: Racial and other Disparities in the Opioid Crisis."

Available Tools and Resources

• SAMHSA. This text includes a chapter allocated to behavioral health treatment for major racial and ethnic groups. SAMHSA also manages the Prevention Technology Transfer Center Network (PTTC) and this presentation covers by the Southwest PTTC covers unique challenges faced by marginalized communities in accessing substance use prevention resources and effective strategies for engaging and empowering all communities.

• SAFE Project has published “Resources for Diverse Populations” which provides links to a suite of resources for a variety of populations. Typically, it will take a combination of several strategies to reduce disparity. Therefore, it is important that there be as much input as possible when considering what needs to be done in a given community.

• United Nations. The UN Partnership on the Rights of Persons with Disabilities and UN Women have published “Intersectionality Resource Guide and Toolkit: An Intersectional Approach to Leave No One Behind." It was developed to help both organizations and individual practitioners address intersectionality in policies and in programs. It aims to contribute to an understanding of intersectionality that bridges the gap between theory and practice.

• JUSTICE SQUARED (Just Leaders for a Just Health System) is a collective which is supported by the Robert Wood Johnson Foundation. It aims to create practical, impactful, structural change to advance health equity and racial justice.

• The Hawai’i Department of Health manages the ‘Ohana Center of Excellence, which provides training and technical assistance for those working in substance use, behavioral, and mental health to better serve the needs of the Asian American, Native Hawaiian, and Pacific Islander (AANHPI) communities through culturally responsive care. Their website provides access to a variety of workshops and research articles.

• "How to Be an AntiRacist" is a best-selling book by Ibram X. Kendi. Since racism is often what is being left unsaid in addressing disproportionality, this book, while not directly about health inequity, provides a broad understanding of racism and other “-ism’s” and includes recommendations for building a more just society.

• The Drug Policy Alliance has published three facts sheets on the impact of the overdose crisis on Black, Native American, and Latinx communities.

Promising Practices

• Arkansas. This project aims to reduce alcohol use among black men by providing screening and brief interventions in a barbershop.