Good afternoon, everyone, we'll get started in just a minute. Good afternoon, everyone, and welcome to today's webinar, Addressing OUD and BIPOC Communities Part 2, How the Opioid Epidemic is Affecting the Latinx Community, hosted by the Providers Clinical Support System in partnership with the National Council for Mental Wellbeing. Thank you so much for joining us. Before we begin, on the next slide, I'd like to cover a few housekeeping notes. Today's webinar is being recorded and all participants will be kept in listen-only mode. The recording and slides will be posted on the PCSS website within two weeks. There will be an opportunity to ask questions at the end of the webinar, so we encourage you to submit your questions using the Q&A box located at the bottom of your screen. On the next slide, we'll introduce our presenter, Dr. Pierluigi Mancini, President of the Multicultural Development Institute. Dr. Mancini is a renowned national and international consultant and speaker on mental health and substance use disorders, with expertise in cultural and linguistic responsiveness, immigrant behavioral health, social and racial justice, and health equity and health disparities. He founded the state of Georgia's only Latino behavioral health program to serve the immigrant population and provide services in English, Spanish, and Portuguese. And internationally, he recently led a project to train clinicians in Latin America who are caring for over 4 million displaced Venezuelans in the region. Dr. Mancini's work addressing Latino behavioral health issues has won six Emmy Awards, and he has been recognized with numerous other awards as well. He currently serves on the Board of Directors for Mental Health America National, WellSTAR Atlanta Medical Center, the Georgia Council on Substance Abuse, and RI International. Next slide. Dr. Mancini has no disclosures, and next slide. The overarching goal of PCSS is to train a diverse range of healthcare professionals in the safe and effective prescribing of opioid medications for the treatment of pain, as well as the treatment of substance use disorders, particularly opioid use disorders, with medication-assisted treatments. And without further ado, I'd like to turn it over to Dr. Mancini to review the educational objectives and begin the presentation. Thank you very much, Casey. Buenas tardes. Good afternoon to everyone. Thank you for taking time of your busy day to be with us today to discuss this very important topic. What we hope to accomplish today is to give you a good understanding of what is the Latino community, the Latinx community, describe the current situation concerning the opioid epidemic and how it affects the Latinx community, discuss treatment challenges for Latinos, and analyze policy issues that need to be addressed. We'll wrap things up with some recommendations and possibly some solutions. Next slide, please. So what is it? Is it Latino? Is it Latinx? Let's explore a little more. Next slide. So Hispanic Americans or Latino Americans are people in the United States who are descendants of people from countries in Latin America and the Iberian Peninsula. So the United States has the largest population of Latinos and Hispanics outside of Latin America. As a matter of fact, there are enough Hispanics or people that identify as Hispanics in the United States who speak Spanish to make the United States the second largest Spanish-speaking country in the world. So this includes foreign-born individuals, and it includes people born in the United States who identify themselves as Hispanic or Latino. It also describes these cultures that were once under Spanish rule, so people always differentiate between Brazil and the rest of South America. Well, Brazil was under Portuguese rule, so that makes them different and their language is different. But they're not considered Hispanic, but they're considered Latinos. So we are the largest minority group in the United States, bubbling at about 64 million, about 18% of the U.S. population, and also the youngest racial ethnic group in the United States with a median age of about 26. It's a term that used to never exist in Latin America, but it was created here in the United States actually by the census. They wanted to simplify a way of counting people that spoke Spanish in the United States. So starting with the 1980 census, we started seeing those differences. Next slide, please. So then you probably heard Latinx, and some people are dead set against it. Even if they don't know what it means, they said, there's no way, that's not a word. Actually, the Real Academia de Español in Spain, which is responsible for the appropriateness of the Spanish language, two years ago, termed it that it is not a Spanish word. I don't know that it was meant to be a Spanish word. Latinx is a gender neutral term, and it's used in lieu of Latino or Latina. So the X replaces the standard O and A that's very common in the Spanish language to differentiate about gender. Today, the term is politicized as a neologism that has gained traction among advocacy groups, intersectionality combining the identity of politics, race, gender. And we do see it in organizations. So for example, I'm a member of the National Latinx Psychological Association. About two years ago, this association made a conscious effort to change Latino or Latina to Latinx. There are others that do not do that. So it's really up to that individual organization. Next slide, please. Also wanted to make sure that we address, you know, the elephant in the room. So immigration, you know, an immigrant is someone that immigrates, a person that comes to a country to take up permanent residence. Next slide, please. And you know, we do have a long history of immigration in the United States, and some of it is voluntary and some of it is involuntary. So let's unpack those terms. Next slide, please. Voluntary immigration is when a head of household or a family makes a conscious decision. They got a job offer, they're going to study, they make a plan to move to another country. That's voluntary. Involuntary, where many people fall under involuntary immigration is when the individual does not really have a say so. And this could be members of the family, where the head of household made the decision and the rest of the members didn't have a say so. But also it could be things like slavery, human trafficking. Those are involuntary immigration. Then you have issues of social pressures and political pressures that causes immigrants to come to the United States under different forms, including refugees, asylees, and then you have documented and undocumented. Now documented and undocumented, the undocumented individual is someone that maybe came without permission, but many of them originally come with permission, but the permission expired and they didn't leave. We have to also make sure that we differentiate because there is a big stigma on undocumented immigrants that everyone thinks, well, those are the people that cross the border and they stand on the street corners and so on. But there are many undocumented immigrants that have nice homes, nice cars, they have money, their permit expired, but they're still in that same category and we need to clarify that. Next slide, please. So a brief overview of the Latinx community in the United States. Next slide, please. There are 44, almost 45 million foreign-born individuals in the United States. Next slide. The population by race clearly shows that even with foreign-born, the largest group continues to be white. And then you have Black and African-American, Asian, and those from other race. Next slide, please. When it comes to age, we also see that foreign-born is the blue line, foreign-born in 18 to 64 outnumber U.S. born in age groups. Next slide, please. And then they're primarily coming from Latin America, but I also want you to notice the 31% coming from Asia. As you know, Asia is more complex. There are many countries, many languages, many cultures, different religions, and that's a big difference between the Asian growth and the Latin American growth. Next slide, please. And then one of the items that people often also overlook is, well, you know, they come here and they just take things from us. Well, about half of the foreign-born in the United States are naturalized citizens. And then other half that are either in process or just having gotten started. But every immigrant that I've ever met does want to move towards citizenship, especially when some laws changed and they allowed individuals to hold dual citizenships. Many people had not done naturalization because they didn't want to lose their home country citizenship, but now many countries allow that. Next slide, please. And then language. So many of you who know me know that linguistic access is one of my primary areas of support. And, you know, in the United States, yes, Spanish is the next language after English, but then you have Chinese and Tagalog, and many people are surprised. It's a Filipino language, and many people are surprised that there is that many people that makes it the third most common language spoken in the United States. So we also have to pay attention to all those other languages that follow. Next one. And then here is kind of to wrap this whole section up. The issue that is involved with immigration, but also with language, and we'll talk a little bit about the barrier of language in a moment, is when you poll the foreign-born population in the United States, 47 percent report that they speak English less than very well. And let me unpack that for a minute. Again, every immigrant I've ever met wants to learn English. Now to master a foreign language, it takes three to seven years, and we cannot expect people to wait three to seven years to get help for their opioid use disorder or any other behavioral health condition. And what does it mean to speak English less than very well? Well, there's different degrees. Someone may be here, and let's say they work as a mechanic, and in English, they can tell you everything that's wrong with the car. They know every single part of that car in English. They know what's wrong. They know how to tell you what's wrong, and that is going to cost $700. Somehow everything always costs $700 when you go to the mechanic. But if you ask that person to tell you about his relationship with his family or any stressors or to describe to you difficult situations they're going through in English, that person will not have or may not have the tools to do that. And that's the big difference in limited English proficiency. They may have some knowledge based on their profession, their expertise, but when it comes to the rest of it, to explain to you suicidality, anxiety, depression, opioid use disorder, they don't have the skills or the language to do that. So that's why the push has to be into providing services in the language that they best understand. And any of you that have traveled to a foreign country where English is not the primary language and something happens, you get hurt, you lose your passport, first thing you say is, who speaks English? Because automatically we'll revert back to our native language. Next slide, please. So let's start with talking about the reason why you came here today. So Latinx and opioids. Next slide, please. Let me start by saying that this 20-year-old opioid epidemic is not the first epidemic in the United States. The first one was actually in 1903, but that's another story. But what does play a role in this that I'll circle back with is in the 1970s, there were many Black and Hispanic individuals who died by opioid overdose. And we did not have the same response that we have today with this epidemic. And so we do see that clearly one of the biggest difference was the demographics, because when this epidemic started, it was not Black and Hispanic, it was white. And the response was completely different to what it was in the 70s. Similarly with the crack cocaine in the 80s and 90s, mostly affected minorities. So the response from public officials during this crisis was to criminalize drug use and enforce mandatory minimum sentencing laws. Those things that happened 50 years ago still play a role today, and it impedes individuals from seeking help because they feel they're going to be punished again the way that it was done 50 years ago. The same thing with media reports and public health approaches. They have focused more on white population, the middle class, and suburban communities. And communities of color have been dealing with opioid and other drug crisis for, like I said, at least 50 years. And then when cheap heroin and prescribed opioids, high unemployment, living conditions, mass incarceration, and institutionalized racism all have contributed to the current state of affairs. Next slide, please. So the question begs, does racial bias explain why whites are far more likely to get addicted to prescription opioids? Well, I think it explains why there were more whites at the beginning of the opioid epidemic. Research shows that doctors are far less likely to prescribe prescription opioids to their Black and Latino clients, making them less vulnerable to develop an addiction to those drugs. Now, the reason why they do that, and the reason doctors prescribe narcotics more cautiously to non-white patients, are pretty clear. Doctors are more concerned about the person becoming addicted or the patient selling their pills, or maybe they're less concerned about pain in that population. And what we have been able to find by speaking with physicians is that many of them plainly said, well, Blacks and Hispanics can handle their pain more. We also found that rates of opioid use in Hispanic and Latinx families are slightly lower than those of Blacks and similar to those of white, but we didn't get the same kind of service. Now, we also realized that many doctors or dispensers would not send opioids to pharmacies located in poor areas where Blacks and Hispanics live because they were afraid of break-ins and that it was going to be stolen. So we can always see that there is many factors that were affecting Latinos to take part in the recovery piece of this epidemic. The past year heroin use, we do see Latinos and whites pretty similar, but slightly lower than Blacks, and we have been able to see increase among Hispanic and Latinx prescription opioid users, and we have higher levels of risky injection drug use compared to white and Black opioid dependence in adults. Next slide, please. So primary substances used by Hispanics and Latinx community members vary by subgroup. This is one of the areas we have to keep in mind. We have 22 countries plus the United States that are considered where Hispanics and Latinos come from, and that is limited because we tend to group these communities primarily under three subsections, Mexicans, Puerto Ricans, and Cubans. Well, there's 18 other places that we also need to, and things vary among all of them. So we do have data from SAMHSA that shows opioid analgesics is lower among Hispanic adults, but we used to have or we continue to have disproportionately impact by opioid use disorders. In SAMHSA reports, 17% of Mexican admissions were for opioids, 49% for Puerto Ricans, 20% for Cubans, and then 22% for other, and it's that other that doesn't get to participate in the research. And we also have the largest rates of uninsured individuals in the Latino community. Next slide, please. So a number of communities in the U.S., and especially the Southwest and Northeast, experience higher rates of Hispanic, Latinx, heroin dependence and overdose fatalities, and this has been happening for 60 years. So this sets the stage for recent increases in opioid use and overdose rates among Latinx in those regions. But there are differences among those regions, including how the drugs get there and ethnic difference within those populations. Now poverty and limited economic opportunity and other social determinants of health also play a role in keeping heroin dependence and threats in these areas. And then regions of the country that cover rural and urban communities where you can find cheap and already available heroin and other opioids, and they were moving, as you know, from the prescription pad down to the street. So that is also happening. I also wanted to start talking about youth. Many of you may have seen last month's report that adolescent opioid overdose deaths doubled. They had a 100 percent increase in 2020. What many people are not aware that when you start dissecting that, the highest group of adolescents in that increase were American Indians, Native Americans. The second were Hispanic youth. Now, that is alarming because Hispanic youth had not been showing up in the numbers, in the rates that they showed up when that report came out. You know, some of the details is Latinx eighth graders are reporting the highest rates of use for nearly all classes of drugs. And in the 12th grade, Latinx are reporting to have the highest use rates for a number of substances, including oxycodone, synthetic marijuana, crack and methamphetamines. Next slide, please. We also wanted to highlight the particular note where Latinx youth who are pregnant adolescents ages 12 to 19. So in a study in the three year period, 2200 pregnant youth were admitted annually to substance use treatment programs, 19.3 percent identified as Hispanic Latino. And the pregnant youth admissions, 5 percent were for heroin and almost 9 percent for non-heroin opiates. In 2020, when the study came out, we were able to start putting some focus into this youth population that had highly been ignored over this time. Now, when it comes to medications, research shows that Latinx adolescents were less likely to receive combined naltrexone and buprenorphine as treatment for opioid addiction, despite knowing that is a best practice for as an early intervention. While the death tolls are still higher in the white community, Black and Hispanic numbers have increased by 45 percent and 52 percent, respectively. So among Latinos, the increase in heroin overdose deaths is a little lower than in the Black community, but only by a few degrees. And we really don't have a good grasp on the trend when it comes to Hispanic Latino communities, and we're trying to pay more attention to that. Next slide, please. So in part, recent immigrants, when all this information comes out, one of the most common or popular ways to spread information is through social networks. But recent immigrants, many of them are less concerned about social networks than other forms of gathering information, and they have not been able to make that shift yet. Now, some of them are able to get information, but what we found is that, you know, good old radio and television continues to be a primary way to get information to them. For those that fall prey to addiction, Latinos still struggle with the stigma of seeking treatment. So not only do we struggle admitting that someone we love or someone we know has an addiction problem, which compounds the fact that I'm not going to acknowledge that I have an addiction problem, but if we do acknowledge it, then it's that shame, a very shame-based messaging that comes out when someone says, I need help because I'm addicted to drugs. So the support of family members often is not there because of the lack of understanding by the family about addiction and the fact that there is treatment and treatment that works. And once they do accept it, if you remember, we go back to limited English proficiency, once they do accept it, if they need it in Spanish or any other language, the United States does not have the infrastructure to provide those services in languages other than English. So we need to continue to work in developing that infrastructure for cultural and linguistic responsive treatment in the United States. Next slide, please. So you can see here briefly the increase in Hispanics on the top right, 137% between 2010 and 2014. I tried to get newer rates on that, but I couldn't. But what we do know is that it's gone up at least another 52% since then. I just couldn't find a graphic for it. Next slide, please. And then I did get current data 2015 to 2020, where you can see Hispanic, Latino is the orange line. On the left, you see men went from 10.9% of fatalities to 27.3. And women went from 4.4% to 7.5%. So fatalities among Hispanic men and women have increased tremendously over the last five years. Next slide, please. So this next few maps, I think I have two of them. This is the opioid overdose death for Hispanics in 2015. And you notice that the black is the highest numbers. That's California, Texas, New York, and Florida. And the dark blue is next and you see Arizona. Next slide, please. And we do keep the same four in black. I'm sorry, Texas turned blue from black, which means they started having lower deaths. But then New Mexico turned blue and Colorado stayed blue. But look at all the other light blues, right? So it was almost a doubling of the number of states where Hispanics have died from an opioid overdose. It's all over the United States. So it was not just the traditional Hispanic, Latino states that we're used to, but the increase is all over the place. And a little point of warning here, when we look at this data, often medical examiner's offices vary within the state. So sometimes people are not categorized in the proper place. So for example, in Georgia, we have a medical examiner that collects data one way at the city level, the county level collects it another way, and the state level connects it another way. So at the end of the day, you have places where race and ethnicity is not asked. So we lose those individuals and places where race and ethnicity is not confirmed. The medical examiner or someone in that office may make a determination based on the surname, for example. Now you want to know, and I know that just because your last name is Martinez doesn't mean you're Hispanic Latino. That is an individual decision to identify as Hispanic Latino. And we also have to remember that people may have that last name because of marriage, or because the Spaniards invaded another country like, you know, the Philippines, there's many Spanish surnames in the Philippines, and they don't identify as Hispanic Latino. Next slide, please. So here, I'm just providing you those links for you to go and play with those websites, you can find a tremendous amount of important information. Next slide, please. So here again, is that chart comparing the decrease of the white overdose deaths and the increase of Hispanic and black non-Hispanic overdose deaths. So you see where the trend is heading. So every demographic now is playing a role here. Next slide. And then for the last 20 years, I'm sorry, next slide, please. There we go. So for the last 20 years, dividing it again in these four categories, American Indian, black, Hispanic, and white, you can see where the differences have happened ending in 2020. And you see black, American Indian and Hispanic overtowering the white community. So we are seeing overdose rates among Hispanic Latino individuals that continue to be lower than black and American Indian, but higher than white. Next slide, please. And then in this one, rate per 100,000 population, you can see the Hispanic Latino is blue, continues to go up, and American Indian and black are the two highest that continue to go up. Next slide, please. And this is just a quantification of the statement I made before because of misclassification of race, ethnicity, of decedents on death certificate, the actual numbers of deaths for certain racial ethnic populations might be underestimated by up to 35%. Next slide, please. So let's spend a few minutes talking about treatment barriers. So when we talk about treatment barriers, you know, there are the historical barriers of affordability, I don't have the money, I don't have the insurance, or accessibility, yeah, there is a place close to me, but, you know, nobody else, nobody there can communicate with me appropriately. And then availability, if there isn't a place close to me, we have counties that don't have a single clinician, period. Even English speakers, we don't, so it may not be there. But we also wanted to highlight two very important items. The first one is, next slide, please, is literacy, right? So when we talk about mental health, and I like to expand that to behavioral health, literacy, it comes from health literacy. Originally, it was conceptualized as knowledge and beliefs about behavioral health disorders that aid the recognition, management, or prevention of those disorders. But it was also later redefined because we wanted to include knowledge that benefits the behavioral health of a person. So the literacy is defined as the knowledge and beliefs people have about their conditions, which helps them in recognizing management and prevention. So not everyone that shows up for treatment understands the westernized view of treatment, or even of a substance use disorder. In many parts of the world, we don't even have the language to call it an illness. And in Latin America, it varies, because people's understanding, you know, if it's excessive drinking or excessive drug use, sometimes the family tends to protect, so they may not have the same information. Now Healthy People 2030 defined health literacy, they actually divided into two sections, personal health literacy and organizational health literacy. Personal health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. Brief example of this, when I had my, so I founded and ran the only multilingual behavioral health agency in Georgia for almost 20 years. When I first started, and we used to do a behavioral health assessment, I hired my first bilingual psychiatrist, and there came a point where individuals were being offered medication to help them in their treatment. And individuals back then, and I'm dating myself, we used to get free samples from pharmaceutical companies, so the doctor would give them to clients who couldn't afford medication otherwise. The clients were throwing it out on the way out, so the waiting room trash can ended up with the samples, and the receptionist caught on to that and alerted us of that. What happened was the individuals didn't think why they needed a medication, because they only associated pills with some kind of physical pain, so they would throw it out. So, personal health literacy, making sure the individual understands how to use that information to improve their well-being. And then organizational health literacy is the focus is placed on organizations, and making sure that they have this, the ability to enable individuals to find, understand, and use that information. So, what we did in the example I just showed you, is we had to make an adjustment, so we added a medication education piece to the nursing assessment. The nursing assessment would happen before the individual saw the psychiatrist, so the nurse would then take it upon him or herself to explain to the individual what it is that they were going to get when they saw the doctor, if in fact they were going to be offered a medication. So, it's not just the matter of knowing, but it's the matter of making sure that we provide the information to the individual in a way that makes sense to them, and they can actually put it into practice. Next slide, please. What I also want to highlight when we talk about Latinx communities, what's called cultural literacy. So, cultural literacy is the ability to converse fluently in the idioms, allusions, and informal content which creates and constitutes a dominant culture. So, you know, this could mean things that becoming familiar with the place where the individual came from, right, not assuming everyone is Mexican, not assuming everyone is from one place or another, but actually making the effort to look at the chart or to ask the question, what country are you from, and having some kind of connection, whether you've been in that country, you've heard anything, or even if you looked it up before the session, you know, saying, wow, the country looks beautiful. Making that connection is part of cultural literacy. It also stresses the knowledge that pieces of information that the individual may assume that you as a provider already have are not actually there. So, it's always good to be able to ask questions and let the individual know, hey, I need you to help me understand this. So, you know, one example of, it's also explaining not only treatment plans, but medications, like I mentioned earlier. So, a true example that happened, a Spanish-speaking client with limited English proficiency was prescribed a medication. The provider wrote the order as usual. In this case, it was take once per day, but the provider failed to recognize that in Spanish, O-N-C-E, which in English is pronounced once, in Spanish is once, which actually means 11. So, the client was at risk of taking 11 pills per day, right? So, things like that need to be paid attention to so we don't make those kinds of, you know, sometimes very dangerous errors. Next slide, please. So, briefly, because these two items can take a whole hour, I want to make sure that we also identify health equity and health equality as barriers. So, health equity is defined as achieving the highest level of health. Equity means fairness. Equity means that the ability for someone to have the opportunity to succeed. So, it's the principle that opportunities for good treatment in vulnerable populations are achievable, and the only way that be achievable is by eliminating systemic, avoidable, unfair, and unjust barriers. So, equity is progress towards achieving. Equity can be measured by reducing the gaps in those health disparities. So, equity is fairness. It's making sure everyone has the opportunity to get better. So, if in your service area you have a large group of Latinx individuals and you know half of them do not speak English very well, then as an organization, the way you're going to achieve equity is by making sure that those individuals also have a process to access your services in a way that they can understand so they can be successful in their recovery. Equality, which many people confuse with equity, equality means the same. It promotes sameness. Now, equality only works when everyone starts at the same level. So, you know, on the top picture where it says equality, everyone gets the same size bike, right? So, it may not be comfortable or even usable for the small child on the right, but it's definitely not usable for the person in the wheelchair on the left. So, equality, you know, if everybody gets the same size bike, it only works if everyone has an able body and is that perfect size. And then when you look at equity, then you have made adjustments. The child gets a child bike, the woman who's shorter than the man gets the proper aid, and then you have the person who was in a wheelchair that gets a bicycle that they can actually use. Next slide, please. And then the last part on this is when it comes to treatment. So, I challenged SAMHSA a few years ago when, because our program was part of the treatment locator, and they had all these programs and this newsletter piece came out in one of the SAMHSA newsletters in 2010. And I'm bringing it up even though it's from 2010 because it shows, right, it shows that there's treatment facilities that provide treatment in Spanish. I said, wow, I didn't know there were that many. Now this was 10 years ago. So I went through the director and I started calling a lot of these agencies and their understanding of providing services in Spanish was all over the board. So some agencies would tell me, oh yeah, if we get someone who speaks Spanish, there is a counselor in our city that speaks Spanish. So we call him and then he can come help us. That's not providing services in Spanish, right? Or some people say we use the language line, right? So we need to be conscious. We need to be focused on how we ask these questions. What does it mean to provide treatment? My personal bias to provide treatment is that you have all of the services that you provide in English available in Spanish. That's providing services in Spanish in a culturally and linguistically responsive manner. Next slide, please. So next slide, please. So again, briefly through these language affordability, we've covered many of these, but then at the end you see systemic and that's when barriers may include at the systems level. It could be the city, the county, the state office that have barriers. And some of those barriers are implicit where they may not even know that they have those barriers until somebody calls out the information for them. And we need to address those as well. And then next slide, please. And we have workforce barriers. Now, I know we have a shortage of clinicians throughout the entire country who speak English. We are gonna be in a big crisis, bigger than now in the next five years, but we need to develop a bilingual, bicultural workforce and it can be done. In my agency, I was able to help over 40 bilingual clinicians achieve full licensure, right? So we can do this. If me and a little nonprofit can do that, we can do this to scale. We also need to make sure that people understand that it's not just the language, but the culture. People have different cultural explanations as to why they're sick, including telling you that it may be a supernatural issue that somebody put a curse on them. We have to be able to navigate through those conversations with individuals that may come from different cultures. There is also the understanding that people may have mistrust when they come to our agency, especially if it's a red brick building that has department of so-and-so for whatever state. Government looking type agencies are scary. So we need to help communities understand that it's okay to come in there. But if they come in there, we need to be ready to be able to serve them. Next slide, please. So the barriers at the individual provider and system levels, at the individual level is what is your intake look like? Do you have to make someone wait 20, 30, 40 minutes for an interpreter to come? Or are you prepared to be able to take the information? And then what information are you taking from them? At the provider level, this has to do with social structure, health beliefs and attitudes. Is your staff, do they understand that people from different cultures view this differently? And do you prepare them for that? And then at the provider level is skills and attitudes as well. And many times these people, you may have people working in your agency that are intolerant to people that speak with accents, that are intolerant to people that come from other countries and we need to address those issues because that's also keeping people out. And I already mentioned system. Next slide, please. And well, we'll just wrap this up for barriers is, bilingual providers, lack of them, interpreters, many, and I'm afraid to say all because I don't like to use all or never, but let's just say more than many interpreter programs do not address behavioral health. Even medical interpreter programs do not address behavioral health. And we have our own language and we cannot afford to have an interpreter be working for us who does not understand behavioral health language because they'll be left up to their own opinions, their own ethnocentric beliefs about addiction to make up whatever they're gonna tell the clinician. And then the last two, these are very real. Even if people have a residency or citizenship or if they have become naturalized, people are afraid to get treatment, even if they're here with all of their documents to be here because sometimes there's, again, political issues that come out of Washington saying that they're going to take your citizenship away if you use public services and things like that. So we need to make sure that we understand that. And then discrimination and racism, they're always part of barriers and we need to make sure we include it. All right, next slide, please. And then next slide. So here's where we are in treatment. Few interventions for Latinx populations. There are a few prevention and treatment interventions that have been developed specifically for Hispanic Latinx population. Many people say, well, we've adapted this. And some are great. Cognitive behavioral treatment, it's been adapted. It's very successful in English and in Spanish. There's some work being done now with EMDR. So we have, sorry about that, I lost my train of thought, intervention. So, you know, we did a project that used to manage two SAMHSA centers, Hispanic Latino ATTC and Hispanic Latino PTTC. And we developed an e-compendium where we took 200 evidence-based practices that were claiming that were appropriate for Latino communities. And we took a deep dive and we started looking as to, you know, how many Latinos were in your study? Where did you apply this program within a Latino community? And then we ranked them one and two stars, depending on how deep they went. So we need to make sure that we continue to address that. And then next slide, please. So we have the different levels of, in acute intervention, emergency, how do we apply an overdose? For example, in Georgia, where I am, you know, we're still, we're not doing naloxone training in Spanish, in Hispanic communities. And we have, you know, 1 million foreign-born people in Georgia and half are Latinos. So we need to be able to have this information in the proper language. Same thing with how we rank withdrawal. Next slide, please. And then how are we preparing in hospitals, residential units, and outpatient programs? I can tell you that in many states, the hospitals, the inpatient hospitals may have, because they have to have the language line or interpreters, they do have some activity. But in many states, if you need residential treatment or even intensive outpatient treatment and you don't speak English well, there is nothing for you. Some outpatient programs are starting to come up. And again, we need to develop this workforce in order to provide it. You cannot provide outpatient treatment with an interpreter. You cannot provide it with a language line. You need someone there that can communicate with that individual. Next slide, please. I mentioned a little bit earlier that Latinos are not being offered pharmacological treatment and we have great pharmacological treatment. Next slide, please. And then psychosocial, when we have specialized programs and these are some of the ones that I have seen and I have witnessed that are available in some places make it very accessible. So I'm able to speak that these are good programs. Next slide. And this, you can look in the handout, they're just treatment resources that you can click on. Next slide. So what's being done? So let me use the last couple of slides, next slide, to tell you what's being done. So, you know, we're using Naloxone, we're training many people to use Naloxone, Good Samaritan Laws, emergency departments. Here in Georgia, we have, it's coming up, Rosie. Here in Georgia, we have people in recovery working in emergency departments. And so they can be ready when someone comes out of an overdose to provide some resources. Next slide, please. We also have physicians when they prescribe an opioid, they're prescribing Narcan. The E-Compendium I mentioned, you can reach it from that link. And then of course, we need to continue to educate Latino communities about the prescription drug safe disposal, because God knows we keep everything in case a family member needs it. Next slide, please. Here you go, Rosie. Harm reduction strategies. So, you know, these have been proven to work. And depending where you live in the United States, some of them are not being used, so there is a strong reaction against them. But we need to continue to move forward and continue to advocate because it is working and it is saving lives. Next slide, please. I'll let you read the policy issues on your own, you know, workforce treatment and language. We do have immigrants who are professionals, who are bilingual, who are bicultural. We need to do better to make sure that they can work here as clinicians. We put many barriers. We need to develop treatment and we need to continue to work on language. Last slide. Next slide, there we go. Thank you. Thank you all so much. I hope you have some good questions for me. Thank you, Dr. Mancini. That was really great, very informative. I just want to note for everyone again that this is being recorded and the recording and slides will be shared with everyone after the webinar. We do have some questions in the Q&A. One of them is when it comes to treatment success, specifically for the Latino population, is there a type of treatment that has been reported to be more beneficial or effective, like peer-to-peer or group therapy or others? Excellent question. So like I said before, inpatient treatment, outpatient treatment, residential treatment, they have been proven to be successful. Pharmacological treatment has been proven to be successful regardless of race or ethnicity. The challenge is that cultural literacy and then the linguistic access. So if the person doesn't speak English very well, they need to be able to have the services in the language that they understand. They need to have those supports around them in that language. They need to have the peers around them in that language. And they need to have the education if they were given pharmaceutical, pharmacological treatments. But like I said before, cognitive behavioral therapy works. It's been proven in any language. And we just need to make sure that we can develop those. Thank you. Great. I'm gonna combine two questions that are kind of similar. For patients who do not have proper ID or legal status, how do you help them get treatment? So in some cases when they need access to Suboxone, but because it's a controlled substance, they're not able to pick up the medication at the pharmacy without an ID. Excellent question. And we've actually had that here in Georgia. So in 2010, Georgia passed a law where anybody that wanted to use state-funded services, they had to show verification of lawful presence. So that put a lot of people out if they're, again, immigration is a very difficult subject and there's many levels. But at the end of the day, if someone is in process to correcting their immigration status, they're still undocumented. They won't be able to access those services. What we were able to do is we were able to work with foundations and other nonprofits. So if a foundation funds services or even the federal government, because federal government does not have the barriers to access treatment, then those individuals can be treated. They can receive the counseling and the support. When it comes to the medication, that became really, really difficult and it was very tricky. Sometimes we were able to work with the consulates. So sometimes the consulates have ability to find medication for their nationals who are living here. So depending where you're living, you may need to do some homework and find out where that individual is from. If you have, what is the closest consulate to you and be able to find information that way. But yeah, any medication that needs to be picked up that you need to show ID. Now it doesn't have to be a driver's license. Sometimes you can pick up medication with your passport. So if the individual has a passport, if they have an ID from their home country, some pharmacies will be able to accept that. Great. Thank you so much. That's so interesting. I've never heard of reaching out to the consulate for support. So that's definitely a new one. How do you see the role of community health workers in helping to make care more equitable? So I'm gonna take that a step beyond. So I love community health workers. Community health workers has been proven in many different levels of research all over the country, how important they are, how much they can change and save lives. What I want to propose, and actually I think I have someone that's gonna start working with me on this, is develop a bilingual, bicultural curriculum to certify bilingual peers, people in recovery, to become certified peers. And those certified peers, we put them to work. Certified peers is a reimbursable benefit through Medicaid and is the fastest way to get services into a community that's not getting anything. So if we have certified peers, begin to provide education, begin to provide support until we're able to build this infrastructure, which still is my dream that we're gonna build this infrastructure, the person will then be able to get the services the person will at least be able to be getting some level of support. It may not be full clinical, it may not be full pharmacological, but they'll be able to start understanding what is happening to me, what is happening and help the family understand this is an illness and it can be treated and the person can get better. Thanks. Great. I think we have time for one more question maybe. Do you have any resources that clinicians or providers can share with their clients who may be undocumented or any other resources? So when it comes to resources in Spanish, I assume is what you're asking. So one of the things that I do is I provide a lot of community, free community education and I'm building this site and there's some information up there already is eldoctormancini.com and you can download free a lot of information that you can share with your clients and more information is gonna keep going up, but there are videos in Spanish, there's fact sheets in Spanish, there's several things that you can do. And also the technology transfer centers I mentioned, the Hispanic Latino when I was running, I ran those for three years, everything I developed was in English, Spanish and Portuguese. So the Hispanic and Latino ATTC and the Hispanic and Latino PTTC also have information in English, Spanish and Portuguese, including webinars in Spanish and fact sheets in Spanish. Awesome, thank you so much. These are really great resources. I think that's all the questions that we have for today. So thank you so much for presenting and sharing your expertise and knowledge with everyone today, Dr. Mancini. My pleasure, Casey. And I noticed you put my email, so anyone feel free to email me if you want some more information, I'll be happy to share what I can with you. And thanks for the opportunity, Casey, I appreciate it. Yeah, thank you so much for sharing your email as well. And as a reminder for everyone, the recording and slides will be posted on the PCSS website within two weeks from today. We're also going to host part three of this series in late June. So stay tuned for more information from PCSS and the National Council. Before we close out, I just wanted to make you aware of two resources offered through PCSS that may be of interest. First is the mentor program designed to offer mentoring assistance to anyone in need of more one-on-one interactions with one of our colleagues to address clinical questions. You can request a mentor from the directory or PCSS will pair you with one. For more information, check out the website on the slide. Second, PCSS also offers a discussion forum comprised of mentors and other experts in the field who can help provide prompt responses to clinical cases and questions. There's a mentor on call every month who will answer any submitted questions through the discussion forum. On the next slide, it just shows the consortium of lead partner organizations that are part of the PCSS project. And finally, the PCSS website, contact information and social media handles are available if you want to find out more about the PCSS resources and trainings that are offered. So thank you all again for joining today. Thank you, Dr. Mancini for your presentation and we hope you have a great rest of your day and week.

OUD and BIPOC Communities

Latinx Community

Opioid Epidemic

Dr. Pierluigi Mancini

Cultural and Linguistic Responsiveness

Treatment Challenges

Language Barriers

Interventions

Cognitive Behavioral Therapy

Social Determinants of Health