Courtney, feel free to let me know when you think majority of participants are in the room. I wasn't sure if Michelle or Dr. Mintz were joining. I think I'm probably just wait till like five after and then you probably started. Awesome. All right. Thank you, Courtney, and all of you for joining. As you heard, we're doing some behind the scenes chatting. So we're going to wait till 1005 to get started. In the meantime, just sit back and relax. All right, well welcome all to today's presentation. My name is Adriana Maldonado, and today we're going to be spending I think a good chunk of time together today so we'll get a little bit more into introductions, but we will be starting off today with our first session and integrating equity into addiction medicine practice developing a shared language. And so, one second, please. I will start with a little brief introduction. So again, my name is Adriana Maldonado I am in New York City. I am part of the ORN as a consultant. I help and support providing trainings in regards to diversity, equity and inclusion as well as work with other organizations on capacity building etc. My background is I am a clinician by training, I actually worked at UBHC so I know the Rutgers system pretty well, and have then moved on into working with nonprofits and the city of New York around substance use disorder suicide prevention, homeless services. So I have an array of various public health experience. So I'm excited to be here with you all to kind of have a conversation, and to also present on this material. So for today, we're gonna be using what we call mentimeter so this is an opportunity in a that we use to allow us to communicate of their throughout the presentation you're going to see question proms polls etc. So if you take a moment you can scan this QR code or you can log in and place this code in there. And this will allow you to see the presentation as it goes along. And then when we arrive to these questions, you can type in your responses etc. I know we also have a smaller group. So if we feel that we're open to having discussions we can unmute ourselves as well, and have a dialogue so as we go. Let me know what what's working for you all again. We want to, we like to use this tool because at times, not everyone feels comfortable sharing. But we also want to find a balance, where we can all have an open conversation. So it's important to know that everything you say here is, this is an open safe space so please feel free to share. So give you a few minutes to add mentimeter. And in throughout the presentation if you need this code again. Feel free to prompt, let me know, and I can add it back on. In the chat function. Courtney will be supporting. So if anything comes up please let me know. And we'll go from there. All right. So, who's in the zoom room. Cute right. So, I am curious to just hear a little bit about you guys and this is also a way to test out a mentimeter so share a little bit about yourself your role, what are you hoping to take away from today. I'm just curious who's in the room I know you all are in kind of the same field. So, feel free to type away and share with a little bit about yourself. Oh, PG-1, Yatrick resident, pickleball, fresh psych intern, New Jerseyan, awesome, learners, great words, I'm also a New Jerseyan, born and raised, Californian, okay, Florida woman, All right, so it looks like we have a few great descriptive words here to kind of get to know each other. A lot is, as you're saying, very early on fresh psychiatric residents and few of location-wise. So thanks for sharing that with me. I hope that what we're going to talk about today really helps to impact and your experience as a physician moving forward and how you provide a cultural responsive person-centered care. So more to come. Let's dive in. So for this morning session, we'll be reviewing and defining some key terms around health equity, exploring data on the impact of equity and inclusion, and then describing the importance of integrating health equity into our work and in organizations, and then talking about social determinants of health and how they can play into explaining disparities in disease and prevalence and recovery continuum. All right. So an important part of health equity is laying down the foundation, which includes reviewing key terms. So this first section, we're going to walk through some key terminology that is used throughout this work. It's important for us to be on the same page with the language we use to kind of have a better understanding of what we're talking about. So we'll start off with health equity. And the key piece here is to recognize, and I'm sure you guys have seen this image and you're going to be seeing it in various ways throughout this presentation. But the key point here is to recognize that equal access is not equitable access. And so as you can see with the image tree, the equal piece of it, everyone receiving the same level of the box does not equate to equal access. So we will dive a little bit deeper into that in upcoming slides. Inequities in health that are deemed to be unfair from forms of injustice, that's how we'll be defining health inequities. Now, health disparities is primarily a descriptive word and has no value judgment necessarily implied. It's critical when we use the terminology health disparities to challenge when we see this word as it being used to miscategorize groups of being somehow responsible for their disparities versus connecting the disparities to the structural inequalities, institutional racism and homophobia, for example. So really recognizing that we often use the terminology health disparity, but we want to make sure that we're not linking it to the person and what their responsibility is, but about it's the system and how they're perpetuating, how the system impacts an individual's health. So we're going to now take a little bit of a closer look at equity and equality. So equity is the concept that in a fair environment, all individuals are given the resources, tools, and support to access the same opportunities as everyone else. So when we look at these images, when we look at equality, everyone is receiving the same resources, regardless of the barriers, regardless of their needs, same size bike that they're provided. Now, when we look at equity, everyone is provided with the resources they need to address the barriers they're facing. So take, for example, the different sizes and wheels and different types. So for the top part, the wheels that are thicker and more kind of for rougher terrain for that bumpy road, the sizing is different of the bikes. And then the accessibility of having a motorized chair for that individual. And so this is the key piece of equity. It's about everyone getting what they need, recognizing the barriers that may exist and under certain circumstances and conditions. So we're going to get into a little bit more. And so in this next image, we're introducing the word justice. So justice refers to a transformative process in which, excuse me, transformative practice in which the process requires us to go from an unfair, unequal or inequitable state to a fair, equal and equitable state. So let's dig a little bit deeper into what this image represents. So we're going to take a look at this. I'm going to ask you all to, I know in the background, it might be a little hard to see, but I want you to see how do you interpret these images? What are, what are some of the, what are some of your observations, differences in tools and resources being used throughout the images, needs for adjustment? Feel free to share your thoughts. All right, so justice changes structural systems, equity changes resources allocated, great response. Equity image doesn't address that one side of the tree has fewer apples, so everyone, though the child can reach them, they still have fewer. Have you guys seen this image before and know all the answers? Because you are right on point. It's easier to pick apples when you have a ladder, but not everyone has one. Very true. So justice temporarily requires more tools. Justice image changes what's available for both. So the child doesn't need the taller ladder anymore. Yeah, these are great observations. And actually they're right on track. This is exactly what we're talking about. So it really definitely shows that you all are understanding these concepts already and implementing them in a way. So that's awesome. So we'll look a little bit deeper, as you all noted. In the inequity piece, one gets more than needed while the other one gets less than is needed. So there's huge disparities created. Like you all pointed out, it's a great observation that although when we move into equality and equity, now the ladders may be provided in equity, so everyone is getting the same piece. Now equity customizes this so that everyone is receiving what they need. But there's a flaw in all of this, which was pointed out, that regardless of the ability to have the resources you need, the resources or the system and the number of apples and resources are skewed to one side. And so when justice comes into play, it's adjusting the system to not only lean in an equitable way so that both individuals have access, but that the resources are available throughout the whole tree. So the apples are available throughout the whole tree and not just more in one area. So yeah, you guys pretty much explained it, which is awesome. I know we have an opportunity. I don't know if anyone wants to unmute here. We can keep going and share anything, any thoughts they've had on this kind of exercise, thoughts on this. I don't want to lose you all. All right. If not, we'll keep going along. All right. So we talked a little bit about terms, kind of just to set the foundation. So let's now dig into why. Why do we do this work? Why are we talking about this topic? Why do we look for equity and inclusion and justice, et cetera? So before we can jump into strategies and how to address disparities, it's important to understand the context of why we do this work. So first off, equity requires a systemic approach to embedding fairness in decision-making process. So as noted here, there has been executive actions that have been put into place to advance racial equity and support for underserved communities through federal grants, research, et cetera. And so this is part of some of the support that is being put into place to further advance this work. We've also seen other executive orders around embedding equality for the LGBTQ and LGBTQ&I communities. And so these are kind of just the starting points of the work we're doing. So when we review health disparity data, we see that across, that we see that data, we see the inequitable access across for substance use, where white individuals seek treatment earlier than Black individuals, which delay health outcomes. Latine, Latinx, Hispanic, I'm sure you've all heard the word interchangeably, are half as likely to seek treatment than non-Latine. Many Black people only receive treatment after court mandated. So this is kind of some of the pieces on the inequitable access to treatment of substances. There's challenges to engagement and access and utilization of buprenorphine. We're going to dig a little bit more into that. But the medications that are utilized for an individual who is impacted by substance use, opioid use, and the necessity to help manage that, there is an inequitable access to that. Then when we look at adverse childhood experiences, there are not equitably distributed among races. So research shows that ACEs impact children's mental health and health outcomes at a higher rate. For example, 33% of Black children and 21% of Latinx children have two plus ACEs. And so with Native American persons reporting the greatest number and variations of ACEs than persons from any other racial or ethnic group. Now I'm assuming, I shouldn't assume, but you've all heard about ACEs and the research study done behind it. And that the more ACEs that a child experiences, the greater the increase of the likelihood of health risks in adulthood. And so as noted, within more of the BIPOC community, two or more ACEs are identified, which put them at higher risk for experiencing negative health outcomes in adulthood, such as obesity, diabetes, et cetera. And again, within all racial groups, Native Americans have noted to have the highest races reporting the highest rates of physical abuse, sexual abuse, parental substance use, witnessing violence, than any other member. So these are just an important piece to understand about the disparities that are faced by the BIPOC community. We also have seen through research that the pandemic has worsened the existing disparities. So as we've all saw when the pandemic came around, the impact that it had on various communities, the rates of death tend to be higher within the BIPOC community. Also, there's been a lot of the recent reports around burnout, and particularly around the pandemic, has shown the impact of the pandemic on frontline workers, primarily those of color who often worked in the health care system, such as home health aides and other frontline were actively working with patients and higher exposure to COVID. And then we also have the disproportionate increase in overdose deaths for communities, for the BIPOC community. And so we're going to dig a little bit more now into that data. So on a national level, just looking at 2022 data, it demonstrates a steady increase in overdose deaths among Black and American Indian and Alaska Natives. In general, we have seen an increase in overdose deaths in all races. Yet here we're highlighting the higher increase among these particular communities. Now, when we look at overdose data of 2020, 2021, and then the next slide, we're going to be looking at 2022 and 2023, we do see a steady increase in overdose deaths. So we're seeing it across all races and ethnicities. Let's show here. So it is doing. Now, it's important, though, to know that there is a bit more of disproportionary in the 2021, 2022 data. If we look at it here, there has been a trend where there has been kind of a continuous trend within whites, non-Hispanic, where the rates have not changed. However, the others have continued to grow a bit. And so particularly within American Indian and Alaska Natives and Black and Hispanics. I always like to point out with these data points, the collection of data and how it's done. So I myself identify as Hispanic Latina. And so it's an interesting piece when we're providing data. Oftentimes, particularly as you can see here, non-Hispanic, Hispanics, et cetera, overdose rates are reported through when an individual coroner reports. And so oftentimes, ethnicity and race can be misinterpreted. And so although we have very great data systems, it's always good to remember that. How are we identifying ethnicity? And how is that being placed into the data we're collecting? That's particularly a piece within the Hispanic community and also within biracial communities. Again, some of this data is collected through death certificates, et cetera. And oftentimes, it's dependent on an individual and what is checked off. And so it's always important to highlight that piece. So now we're going to look a little bit into New Jersey overdose data, because you are all in New Jersey right now. So unintentional overdose in New Jersey have sharply increased since 2015 and peaking around 2017, 2020. In recent years, there's been a troubling rise in deaths amongst Black, Hispanic, Latino communities, as you can see here in the data, with the blue line being those white individuals where there was a spike, and then there has been a showing a trend of reduction. And however, with Black and African-Americans and Hispanics, the green and the more brown line seeing an increase with no reduction. And so it's important to note that although there's different trends going on, it underscores the urgent need for targeted public health interventions to address the disparities in these more vulnerable communities. So that's the big thing. When we look a little bit more interesting information on intentional overdose deaths in 2020 and breaking it down, this was the most recent data I was able to find. We see that death rates are highest among males ages 25 to 54 with significant disparities compared to females, particularly the age 25 to 54 age range. Males are over three times higher. As age increases, the rates decrease, but males continue to have the highest overdose rates in all age group. And then when we look specifically at substance breakdowns, opioids, especially fentanyl, are the leading cause of overdose deaths with rates nearly 30 per 100,000. And then stimulants, but again, and then the opioid epidemic being impacted by the heroin prescription overdose as well. I share this data because it's important to know as you all transition into your career as physicians, as you work with populations and communities, being mindful of which communities are at higher risk. As we noted before, it's important to do targeted interventions. And so as we've seen within the BIPOC community, also the age range is important to recognize. Sex is important to recognize. And then looking at the substances as well. Oftentimes where there's assumptions that an individual overdoses because of heroin or illegal substances, et cetera, it's important to note that oftentimes there are prescription opioids involved, as well as there's oftentimes an important thing to note of the recent trends in fentanyl and how they are being integrated and laced into other substances. And so as you can see here, take for example, cocaine, all stimulants are also at a high rate. And recognizing that often these times these substances could also be impacted with fentanyl and other synthetic opioids. So just kind of shaping a little bit about the community and the individuals as you work with them and pieces to keep in mind. A little bit more. So there is though some encouraging news. So while total deaths are down, as we noted, the overdose deaths are rising among some. So experts, Department of Health caution that the trends are encouraging. Yet, particularly among white residents, yet among communities, including Black and Hispanic residents, are disproportionately still impacted by overdose rates. So again, keeping an eye on the communities that need targeted interventions. So when we're looking at treatment disparities is another piece of this puzzle. We see that when we look at treatment disparities, they have been well known for years. It's not a new concept. We've been fully aware of how these challenges exist in the treatment options and availabilities. So with it, lack of cultural responsive care in the health care workforce is an issue that has been documented in research and literature for years. And then the issue extends to substance use and mental health treatment. And older Americans are increasingly seeking treatment for substance use disorder. Black Americans are less likely to finish substance use disorder treatment and are more likely to be asked to leave before treatment is completed compared to their white counterparts. So here we're looking at the impact of how the treatment system has impacted the individual's BIPOC community. And so what resources are available to them? What is offered in cultural responsive care? As we're seeing, rates of an individual completing Black individuals are at a higher rate of not finishing treatment. What is impacting that? What is causing that? Is it how the system of treatment is put into place? Is it the cultural responsive piece? Does it not resonate with an individual? These are the questions that we want to explore and learn together about. And we're going to be doing some exercises to better understand how our cultural beliefs, our biases, et cetera, can impact the treatment opportunities offered to individuals. So this one's always a great, just important statistic to show, especially as you are all future physicians and will be working within the health community. So more than three in five people who die from a drug overdose has an identified opportunity for linkage to care or lifesaving actions. So that's about 60% of people who died were a missed opportunity for linkage to care. And so reflecting the need for increased harm reduction strategies, the saturation of naloxone into communities, the education of the utilization of naloxone. And it also reinforces the need to just overall integrate harm reduction into our continuum of health and reduce stigma around the utilization and what harm reduction is. Keeping people alive is the only way we have of getting people into recovery. And harm reduction is an integral part of that. So I think that's an important note to make. All right. I've talked a lot. So I want to hear a little bit from you all. And so reflect a little bit on your local, regional, current events or own experiences. What examples of health disparity have you seen? I know that you're currently in New Jersey, but also come from different areas. So feel free to kind of identify where, maybe where your location is that you're sharing from. But I'd love to hear kind of examples of health disparities that you've seen. And again, you can share a Mentimeter. We can unmute and talk. I'm sure you all don't want to hear my voice all day. So access to insurance changes what treatment some has access to. Yeah, that's a great point. Access to health care. It really does impact what treatment an individual may have, what medications, MOUDs, medications for overdose, opioid use disorders are offered, are based on what insurances will cover, how much time in treatment an individual is provided, how many days, et cetera, is impacted by insurance availability. Health care deserts. Transportation, okay, yeah, language barriers. Yep, documentation is a big piece. So various roadblocks that an individual is facing and their ability to access health, healthcare, language barriers, documentation status, being able to provide identification, transportation, being able to access treatment, get there. I know one of the biggest challenges is when I used to work with clients was they needed to be able to go to the methadone clinics. They were not due to insurance reasons. They were not provided with take-home buprenorphine, et cetera, they would have to go to the clinics to pick up the vials, get it administered there. And there was transportation challenges. So now it's a challenge of getting transportation there, having to go every day, stand in line at six o'clock in the morning, insurance, not willing to cover certain parts. These are all the different barriers that are put into place. These are great points. I'm curious if any of these responses, if anyone's kind of open to just having like a conversation about that. I mean, I'm interested about the healthcare deserts and learning a little bit more about that and what you're sharing there. Similar to food deserts, they're just areas geographically that have less access to medical professionals of any kind. So, I mean, even if like similar to how transportation can be an issue, we have to travel a long distance to get there. It's just problematic for a lot of people who have to deal with a lot of other factors as well. They make it difficult to access healthcare. Great, thank you for sharing that. Thank you, that's really helpful. Yeah, also kind of when we're thinking about availability of healthcare and location, right? So more rural areas, what's available versus maybe more populated areas. And I know that that's also a piece with overdose, with MOUDs is oftentimes doctors, physicians that can prescribe medication aren't always readily available. And so in certain areas, it's hard for an individual to go get these medications. And there's been a great work and advocating for telehealth and being able to do this. So thank you, I appreciate you coming off mute. And sharing a bit about it. I always, there's always one that helps a girl out here. I appreciate it. All right, so now we'll, we talked a little bit about health disparities and next we're gonna be jumping into the conversation around race and why it's so critical one to have this conversation, but also how does it impact equity and justice? And so race while not grounded in biology or genetics is a powerful social construct that deeply influences lived experiences. It remains one of the most significant predictors of life outcomes, transcending social economical barriers. So the, and I'm sure we've all seen on the news and in other pieces, there's has been an ongoing backlash against critical frameworks like critical race theory, particularly in areas and regions where complex historical situations and legacies. And so this highlights actually the pressing need for honest and critical engagement with issues around race and being able to have open and productive conversations. There's a lot of misconceptions out there. There is a lot of framing of critical race theory, et cetera, which impacts how we openly have these conversations. So it's important to note that racism is a form of trauma and it must be addressed as such within comprehensive trauma-informed care frameworks. So effective trauma-informed care necessitates a deep understanding not only of how trauma affects the lives and well-being of clients, but also the underlying cause that contributes to the trauma. And this approach ensures that care is both responsive and attuned to the specific experiences of those affected by systemic inequality. So it's important to take a moment and just sit with this and think about as you progress in your career, how as you work with clients to recognize how race as we're putting here is a form of trauma and how can that impact an individual and how will your practice and your experience and your way of care will be trauma-informed? And we'll talk a bit more about that, but I think it's important to sit with that a little bit. And I don't know if anyone, I don't have a prompt for that, but I don't know if anyone has a thought on this or a comment. No? All right. For time's sake, I'll keep going along. But I will note, as a trained therapist, I am very comfortable with silence, but for time purposes, we'll keep going. All right. So when we talk about race, though, it's also important to recognize that all forms of inequity intersect and accumulate with race and influencing it and interacting with every social system. So we identify the importance of race and how it impacts an individual. However, and with that, we want to also frame it in that inequities also intersect with other pieces of who we are. So in, I believe, 1989, Kimberly Crenshaw introduced the concept of intersectionality, and it highlights how race can intersect with various identities, such as age, religion, immigration status, education, socioeconomic status, and geographical location. And this creates complex layers of power and disadvantage, and these intersections are crucial for addressing multifaceted natures of inequality. So again, when we already recognize the challenges with race, the concept of intersectionality, it demonstrates how other parts of our identity come together to create inequities or privileges, which we'll dig into more in the afternoon session. So structural racism, just digging a little bit more deep into, it permeates multiple institutes and systems, and it leads to barriers that limit opportunities and exacerbates health disparities. So these barriers are not the result of intentional discrimination, but are the outcomes of how public and private institutes interact, reinforce patterns of disinvestment and inequity. So in the context of substance use prevention, treatment, harm reduction, and recovery, these systemic interactions create additional challenges, underscoring the pervasive impact of structural racism on health outcomes. Intent to discriminate is irrelevant. The structure themselves perpetuate these disparities. So when we're looking at structural racism, it's the way in which society fosters the racial discrimination through various systems, housing, education, employment, access to mental health, as you all noted, the criminal justice system. So I want to ground ourselves a bit into that because we're going to transition now into a little bit more discussions on the racial disparities and how these structural systems impact it. So with this slide, the slide focuses on the racial disparities in treatment for opioid use disorder, a critical aspect of the current addiction treatment landscape. So we have some key points here. So some of my key points I'd like to highlight, and feel free to read off the slide. So disparities in follow-up care. Black patients who survive non-fatal overdose are half as likely to receive follow-up OUD care after discharge from the emergency room compared to their counterparts. The lack of follow-up care significantly impacts their recovery chances and increases the risk of further harm. And so there is actually data out there, not specific to Black or BIPOC communities, but about the risk of lack of follow-up care post-emergency visits due to an overdose and how it increases the rates of potential life-threatening overdose or death. And so there is already data out there from a general sense, and so then to see the data of how it's a greater likelihood within the Black community speaks volumes. The impact of racial segregation. So racial segregation plays a significant role in limiting access to methadone and buprenorphine, which are key treatments for OUD. This segregation creates disparities in treatment availability and further marginalizes community of color. So as we noted, as I shared before, with the availability and access to buprenorphine versus methadone, which is available to who, what insurance will cover, which is less stigmatized. These are all pieces that play a factor in the racial disparities in treatment. And then kind of continuing with buprenorphine, there's an increased uptake of buprenorphine primarily around white individuals and those with employer-based insurance, reflecting racial and socioeconomic equalities and access to the essential treatments. Again, reinforcing this conversation that we've been having on how health insurance, access to health insurance and access to medications, et cetera, and who gets access to what is important to recognize. So when we look at the criminal justice system, it shows a dramatic overrepresentation of racial and ethnic minorities. And particularly when we look at it from the lens of substance use disorder and utilization of substances. So in Michelle Alexander's book, The New Jim Crow, it sheds light on the pervasive institutional racism that has led to mass incarcerations in the US, politically targeting people of color. Take, for example, the drug-related offenses that we see, and data has shown that 85% of individuals who use, buy and sell illegal drugs in the US are white. However, 75 of those incarcerated for drug-related offensive are people of color. This disparity highlights that white privilege in the criminal justice system, where drug offenses committed by white individuals are often treated more leniently, while people of color are disproportionately subjected to random stop and searches, harassment, and that the institutional racism within the criminal justice systems lead to significant and equitable consequences for communities of color. So a bit about recognizing the impact of the racial disparities in the justice system, and as we noted there, 85% of substances are utilized by white individuals with yet higher percent, when the majority of the percent of those in the criminal justice system are individuals of color. Um, okay. There should be a video here, but maybe later on. All right, um, so myths about race and racism. So, race is biological. I don't see color, it's poverty, it's not race. Racism versus racism, race is racist. So, we've heard certain, some of these quotes, these terminologies, well, you know, race is biological, or, you know, some of our, I've had family members who say, I don't see color, I love everyone. Everyone's the same, I don't care if you're green, purple, blue, white. You know, understanding that the social constructs of race is crucial in addressing how myths relate to race and racism within our work in substance use disorder. Although, it's important to note that although race is not a biological, genetic reality, it is a powerful social construct, and denying these experiences or claiming to be colorblind dismiss the significant impact that race and racism have in the US, effectively ignoring the disparities faced by communities of color. We also see that the intersection of poverty and race further exacerbates these effects, leading to harsher outcomes for marginalized groups. So oftentimes you may hear, oh, well, you know, it's poverty, it's not about their race, it's just that, you know, it's lack of resources in regards to finance, no job, etc., and not recognizing how race plays a role into all these disparities and equities. Let's see. And so according to Ibram Kennedy, race can be defined as a social construct that creates power differentials, while racism is a replacement of these disparities through interconnected systems and structures, and then those who support racist policies, whether through action or action alone. Inaction contributes to these injustices, and silence and positivity, therefore, forms of compliance that perpetuate the systems of racism, and so it's important to recognize and address these dynamics, and to kind of have these conversations about the myths around race and racism. And when we hear these terminologies, and to recognize how for some, you know, it may be that they're just saying it in a way, like I don't see color as a positive thing, as if they want to be united, where, you know, I want, but it's important to sometimes have a little bit more of a conversation of what that means. Okay, so here's another chance for us to interact. So of these myths about race, which one do you think is more challenging in the context of our work in substance use services, or in the, excuse me, the healthcare system in general, in work in healthcare? It's poverty, not race. Poverty, not race. Okay, we have a So we have a pretty clear myth that you all are identifying that is a challenge, particularly in the context of your work. So I'm curious a little bit about why. So feel free to type it in and we might take an opportunity to have a dialogue as well. I mean, I think all of the things that you just said are examples of how people try and avoid the context of race in dealing with these problems. I think it's a lot easier to think about poverty, per se, and how people are able to access different resources because it's more tangible. It's more like, oh, if it's just poverty, then if I give this person the resources they need, then it should all be solved. It's like a slightly simpler solution than race, which is a much more complex, deeply ingrained problem that is... And while obviously poverty is also extremely structural and a whole other can of worms, it's a little bit more straightforward to say, okay, well, if this person is poor, if I just get them connected to resources like Medicaid or transportation that they don't have access to, then it will be solved. But it's not that clear and it's not that easy. Yeah. Yeah. Thank you for sharing. Yeah. No, you make some great points how focusing on the poverty piece is a bit more comfortable at times. Having that conversation can be a bit more comfortable. There is maybe more of a perception that there's a solution. And so we want to solve. It's comfortable to think about, okay, well, if I do checklist X, Y, and Z, we can address this. It also deflects and takes away overall systemic responsibility. Like you said, poverty is a much more convoluted process and there's more to talk about it and there are system challenges there. But when we compare it to conversations about race and inequity, there seems to be an easier ability to grasp it, feel more comfortable having the conversation. We can push aside that uncomfortable piece about talking about race. I can see you all staring blankly at the screen. I don't have much to add. I definitely agree with what you were saying, that it's just easier to focus on economic structures and how we solve them than racial structures, which are more nuanced and embedded in culture and psyche. Awesome. Thank you. Anupa, I can always count on you. I knew it. I also think from a healthcare perspective, we have such a limited amount of time as a resource when we have to see lots of patients in a day. And dealing with racial disparities is a lot more of a relationship-building type of process. And having that more cultural sensitivity can take a lot more time and be a lot more nuanced than say, okay, I'll just refer you to these social services. I will give you these handouts as who you can call to get these things. Again, I think it links back to what's easier to do from a provider standpoint. Yeah. Thank you again for sharing. I appreciate that. And you make a great point. Yeah. We have these conversations and important to recognize these pieces, but we also have to acknowledge the reality of what working in the system is and the timeframe and how many clients do you need to see and documentation needs to be completed. And it has to be a certain way because Medicaid reviews it and et cetera, et cetera. I understand I've been there. So some of the stuff kind of not gets, yeah, so I can refer you, et cetera. And so you make some amazing points. And later on in the next half of our next session, we're going to dig a little bit into what are kind of better understanding things that as individuals we can do that in the moment impact some of these conversations. Recognizing, and I appreciate you putting that out there, recognizing that as a system, there is a challenge. The healthcare system at times may not allow for that personal one-on-one kind of person centered care per se. And so that's a system issue. That's something that needs to be addressed at a systemic level. So, all right, I'll keep moving along with the silent ones. That's okay. All right. So looking a little bit more into the justice system and drug policies and just systemic racism, drug policies in the United States has historically supported systemic racism and contributed significantly to health disparities among racial and ethnic communities. A stark example of this racial response is evident in how drug use has been handled differently depending on substances and populations affected. So, for example, law enforcement approach to the crack epidemic primarily targeted Black communities, leading to more severe sentencing, and disparities between crack and powder cocaine offenses. Again, recognizing there were disparities there and the perception of a utilization, what populations were using crack, primarily Black individuals versus powder cocaine, White individuals. In the contrast, the opioid crisis, which has more significantly impacted White communities, primarily starting and getting, I'm not sure if you all can recall, but primarily it became in Bolivia, it was up north in New Hampshire, Rhode Island, one of those where there became a lot of news, that overdose were occurring, et cetera, and it was significantly impacting White communities and has seen a response centered around funding for research, treatment, and rather than more punitive measures. And these disparities are still evident today in the access to treatment and lifesaving medications. As we've noted, Black and Latinx people are more likely to be prescribed methadone while buprenorphine, which is often seen as less stigmatizing, is more accessible to White individuals, and the segregation of treatment options perpetuates racial inequities in healthcare. So, again, recognizing these various factors on how drug policies and the overall criminalization of the utilization of substances, misuse of substances, access to treatment, et cetera. All right. Here it is. All right. So, now we're going to watch a quick video. This is the History of Racist War on Drugs, and it's a video that was developed a few years back by Jay-Z and an acclaimed artist, Molly Cabarapple, and it depicts the drug war's devastating impact on the Black community from decades of biased law enforcement. If you all If you may recall, during President Nixon's presidency, many drug-related laws were put into place, and then when we also had the War on Drugs campaign under the Reagan administration, it really perpetuated some of the language and the belief systems around substance use and ultimately impacted communities, BIPOC communities. So, we're going to do a little watching, and then we'll go from there. War on Drugs that had been started by Richard Nixon in 1971. Drugs were bad. In 1986, when I was coming of age, Ronald Reagan doubled down on the War on Drugs that had been started by Richard Nixon in 1971. Drugs were bad. Fried your brain. And drug dealers were monsters. The sole reason neighborhoods and major cities were failing. No one wanted to talk about Reaganomics and the ending of social safety nets, the defunding of schools, and the loss of jobs in cities across America. Young men like me who hustled became the sole villain, and drug addicts lacked moral fortitude. In the 1990s, incarceration rates in the U.S. blew up. Today, we imprison more people than any other country in the world. China, Russia, Iran, Cuba. All countries we consider autocratic and repressive. Yeah, more than them. Judges' hands were tied by tough-on-crime laws, and they were forced to hand out mandatory life sentences for simple possession and low-level drug sales. My home state of New York started this with Rockefeller laws. Then the feds made distinctions between people who sold powder cocaine and crack cocaine, even though they were the same drug. Only difference is how you take it. And even though white people used and sold crack more than Black people, somehow it was Black people who went to prison. The media ignored actual data to this day. Crack is still talked about as a Black problem. The NYPD raided our Brooklyn neighborhoods while Manhattan bankers openly used cocaine impunity. The war on drugs exploded the U.S. prison population, disproportionately locking away Black and Latinos. Our prison population grew more than 900 percent. When the war on drugs began in 1971, our prison population was 200,000. Today it is over 2 million. Long after the crack era ended, we continued our war on drugs. There were more than 1.5 million drug arrests in 2014. More than 80 percent were for possession only. Almost half were for marijuana. People are finally talking about treating addiction to harder drugs as a health crisis, but there's no compassionate language about drug dealers. Unless, of course, we're talking about places like Colorado, whose state economy got a huge boost by the above-ground marijuana industry. A few states south in Louisiana is still handing out mandatory sentences for people who sell weed. Despite a boom in its celebrated 50 billion legal marijuana industry, most states still disproportionately hand out mandatory sentences to Black and Latinos with drug cases. If you're entrepreneurial and live in one of the many states that are passing legalized laws, you may still face barriers participating in an above-ground economy. Venture capitalists migrate to these states to open multi-billion dollar operations, but former felons can't open a dispensary. Lots of times those felonies were drug charges, caught by poor people who sold drugs for a living, but are now prohibited from participating in one of the fastest-growing economies. Got it? In states like New York, where hold the marijuana press, police issue possession citations in Black and Latino neighborhoods at a far higher rate than other neighborhoods. Kids in Crown Heights are constantly stopped and ticketed for trees. Kids at dorms in Columbia, where rates of marijuana use are equal to or worse than those in the hood, are never targeted or ticketed. Rates of drug use are as high as they were when Nixon declared the so-called war in 1971. 45 years later, it's time to rethink our policies and laws. The war on drugs is an epic fail. All right, so I'd love to hear what issues stood out to you in the video, which issues reinforce systemic racism. Just kind of what are your thoughts on the video? What did you see? Discrepancies between crack and cocaine in terms of punishment, yes, it's one of the pieces that they highlighted and kind of talked about, right, the incarceration rates of the perceived use of the substances, but also the stigmatizing or the labeling of the use. disproportionate rates of policing in minority communities. Drug use is seen as a moral failing, the cause of poverty, rather than a response to helpless, hopeless situations, particularly when it's black people using. Awesome, yeah. It's a great point, right? There is a, kind of what we were talking about before, the, when we talked about health disparities and making it a label about it being about the person and they're doing, or, you know, so substance use, it's they're doing, their choice, et cetera, versus kind of what other factors come into play. Covering up defunding welfare programs with monetization of results in public health crisis. Funding of defunding welfare programs, monetization of results in public health crisis. That's a good point. Funding of the welfare programs. new systemic barriers, perpetuating injustice rather than attempting to resolve them. Right, so new laws, structures, things put into place that are perpetuating injustice. All right, thank you for sharing. I appreciate you guys. I know it takes a while to type it all out. So thank you. All right, we're gonna, I'll keep on going. All right, so now we're going to dig a little bit into social determinants of health. So when you hear social determinants of health, what words come to mind? What do you think of? Zip code, sorry, race, income, trauma, socioeconomic background, transportation, okay, accessibility, location, access, access to food, access to transportation. Race. Health literacy. Yes. we often tend to not, I appreciate you, you know, you guys noting the health literacy piece, and I've seen it throughout different responses, we often tend to not forget, but not keep in the forefront of the impact of health literacy and person's understanding on their their well being and their overall health. So that's a great point. These are all great responses. And yeah, you're pretty, pretty on track. All right. So quick overview, social determinants, health, it refers to interest, intricate and interconnecting social structures, policies, economic systems, that shape the social and physical environment, healthcare access, and broader social factors. And these determinants are the primary driver behind most in most health inequities, as they influence a wide range of health outcomes and disparities. So some examples, as we noted, social determinants, health play a crucial role in the shaping of health and well being. So let's take, for example, economic stability, education, social and community context, healthcare access, and neighborhood environment intersect in ways that can either promote health equity or hinder it. So a lot of the items that you all placed in the chat are what we're highlighting here, these factors that play into a person's can either promote health or hinder it. When these determinants align positively, they foster healthy communities. However, when they intersect negatively, they create barriers, and it prevents individuals and communities from achieving health equity. And when we look at, you know, the impact of social determinants of health, it's important to recognize that it, there's a, it's in the system, there's at the individual level, and then we go into more of the interpersonal, the community, the societal. So I know these are small print, but it really shows kind of, you know, at the individual level, level, trauma and resilience, withdrawal symptom management. And then at the interpersonal level, it's substance use, identification and prevention, education, as we are, we're noting naloxone in education and caring, community level, it's, you know, access to MAT or MOUD, culture specific providers, you know, at a society level, is housing stability, economic wellness. So really, it's, it impacts multiple places within our structure in our system. So the correlation, so how do they, social determinants of health impact substance use disorder? The correlation between poor health and structural factors such as poverty, lack of opportunities, and standard living and working conditions is evident in the prevalence of substance use disorder. So economic hardship, social isolation, social isolation, and untreated mental health disorders compounded by lack of stability, stable housing contribute to significantly contribute significantly to substance use disorder, especially in impoverished, impoverished communities. And also counties with the lowest level of social capital experience the highest overdose rates underscoring the critical need for viable employment, safe housing, community reinvestment to address these disparities. Again, really speaking to those items that you all wrote in there, in the in the prompt, employment, access to housing, you know, all the other points, your food, all of these are items that you all noted, that are important to that are impact can impact these, the substance use disorder. So, if, so how do they show up in substance use disorders? So if I were to ask you to outline how social determinants of health show up in substance use disorder, what would you say? So we're looking at barriers to prevention, how, how do they show up in the barriers? Barriers to care in general, engagement and retention and treatment, barriers to recovery, how would you say you've seen them? And I know we've touched base a bit about it, but to think about experiences if you've had personally or also seen with with working with patients, etc. I'm curious just to see what are some of the barriers you've seen? Language, language, transportation, language, time off, lack of support, language. Immigration status, lack of housing, lack of transportation, public transportation, feeling demonized, cultural perceptions of treatment. We're going to dig into that a little bit, kind of the understanding of the cultural pieces and the cultural responsive care. Yeah, these are really, I see, and these are very, I've seen these, oh, child care, that's a new one, I haven't seen that one. I've seen many of these as I've done this presentation, and particularly here, I'm, in general, language often comes up as a huge barrier. And I'd kind of love to hear from you all, where are the challenges there? Where are you seeing the barrier existing? We often talk about in the healthcare settings that there is, I know there's translation services, et cetera, but where are the challenges there? What is the barrier? You have substance use programs that are speaking Spanish, yes. Whenever you're dealing with patients that take, use different languages, you have to use a translation service, and then treatment, like, at least three times longer, so when you're already busy with a busy schedule, having to put in the time, and besides that, the game of telephone, you're playing with the translator is awful. Sometimes, I can understand the translator, I know they're not translating exactly what I said, and it's not like they're making it, they're doing it on purpose, they just mess up, and then on top of that, if you compound that with health or medical literacy, and not understanding what we're talking about from a conceptual standpoint, it's just so difficult, the level, the change in quality of care due to language is hard to really like grasp. Yeah. Do others agree with that, have had similar experiences? I see some head nodding. Yeah, definitely resonate with the interpreter, not interpreting exactly what you say, and then it becomes a miscommunication, and then it compounds with if someone has low health literacy, so it kind of like, you take a step backwards because they misunderstood, or the interpreter was wrong, and then it just, it can kind of spiral from there. I also feel like having to go through an interpreter, especially if they're over the phone, creates like, another sort of emotional wall between you and the patient, where like, they might be translating your actual words, or the patient's actual words, but the sort of more subtle tone, and specific language used, cues are lost, so you get kind of a flattened version, and there, and I feel like so much of this kind of care is also like, connection building, relationship building, so that is so much more difficult when you have to go through a translator. Yeah, appreciate you sharing that. Building off that a little bit, I think one of the other things that happens is relationship building for people like, in groups, and if you don't have somebody who speaks the same language as everybody else, they can't really participate in those groups, whether it's outpatient, or an IOP, or like, groups in an inpatient setting. Yes, yeah, that is, that is a great point, honestly. I appreciate you guys sharing a bit more about this, because I do think it's important to recognize, you know, oftentimes, we, we hear language as a barrier, but we don't dig deep into why is it a barrier, so oftentimes, we just think it's, oh, the person doesn't understand the language, again, we're placing it on individual, or even the caretaker, or excuse me, the, the provider, or, you know, the, the, the, the, the, the, the, the, the individual, or even the caretaker, or excuse me, the provider, the provider doesn't speak the language, etc. But it's a system situation, right? It's, okay, you have translators, but are they only linguistic translators? Or are they culturally translating? Do they understand the nuances of the culture, barriers of the phone? The, the difficulty on also on your workload, and how does that impact your ability to, to provide person centered care? I don't, you know, it, I'm sure you all want to engage with your, your clients and provide them the care they need. But I also see how the system, right, we need to follow certain procedures, do certain pieces. And so that's important to recognize the in the group setting, you thank you for sharing that is such an important point. I used to run a lot of group therapy sessions. And at times, yes, we had only primarily Spanish speaking client. And yeah, there was it was difficult to to engage them in certain groups, because no one else in the group spoke Spanish. So I'd be able to engage them on the side every so often, but his peers, and so yeah, it limits the quality of care, and the overall effectiveness of the treatment modality, right? The purpose of group therapy is to interact, engage with peers, learn from each other process, and that's limited. So these are, yeah, these are really great pieces. And I'm, I'm curious to hear from you, like, we've, how is how are these pieces that you're talking about? How do you see it? In your experience with engagement and retention? Do you are you seeing many of the individuals you see kind of just drop off? Don't see them anymore? I think people definitely check out because as frustrating as it is for us to have to use like the translator service, it's also equally frustrating for the patients to use the translator service. So there might just be a sense of like, it's not worth it to deal with this. This isn't helping me. Yeah. Yeah, no, that's a great point. If, if you're also frustrated, right? And then if you're in a moment of, you know, needing care crisis, whatever it may be, having to wait for this extra layer, or as we were just talking about this, the telephone game does impact. As we were just talking about this, the telephone game does impact person's ability to respond or willingness to be partaken in treatment, which speaks to kind of some of that information we were talking about before of lack of completion of treatment, not completing, not entering treatment in general, or, you know, partaking in harm reduction strategies, etc. Because the health literacy is also not there, as you all noted. So those are all really important points. Awesome. All right. So I got one more question for you all. Before we, we take a break. What questions does this leave you with? Okay, what can we do as residents? So wanting to get into the strategies, what can, what can be done? Being aware helps, even if we can't fix everything all at once. Yeah, yeah, awareness and we're gonna, we're gonna kind of get into some of the stuff that in the next session that that can be done and it's a big part of it is the awareness. What does justice look like in a mental health clinic? Oh, I like that one. What can we do as individuals versus a system and a structure? Yep, great. So we'll definitely be covering that in our next piece. But but come with, you know, more, more thoughts on that and more questions, we're going to be doing some exercises around that. I think it's important to dig into what exactly is it that you're seeking to learn? Strategies to deal with our own biases, frustrations, counter transference. You got it. That's, did you see the slide deck ahead of time, because we're going to be jumping into some of that stuff. That is really good. At what point does individual responsibility play a role in treatment? Interesting, okay, yeah. So the role of, when you say individual responsibility, is it like the individual, like the patient's responsibility when their role, what their role, okay. That's a great, yeah. What point does individual responsibility play a role in treatment? I think that and the, what does justice look like in a mental health clinic are definitely, and I'm just gonna plug a little, a little follow-up with Courtney of, I think these are great pieces for follow-up conversations because they're definitely, All right. Anything else? All right. So with the next section that we're going to do at one, if I'm correct, you guys take a break and all that, we're going to do practicing cultural humility, self-reflection inquiry. And that one, we're going to jump into some of that of how do we address our own biases? How can we make change at an individual level? Our person-centered care, trauma-informed care, et cetera. So we'll dig a little bit into that in the next session. And a reminder with that is there is another Zoom meeting to use. So remember to log in using that other Zoom meeting. But before we go, I'm going to stop sharing. I do want to hold on. I really should learn how to use Zoom. I used to be like technically savvy at some point, guys, I swear. Anyways, I do have a question for you all. And if you're willing to share stuff, I just want to, before we jump into the next session, because that question prompted me of the mental health clinic and stuff, just hear a little bit more from you of kind of where you're currently like, are you doing your practice or your work or whatnot, just to better get a better sense of the work you're doing and what you're looking for, or kind of what are the pieces that we can continue to explore in this training or discussion? Are you guys working in mental health clinics? Are you all in like Piscataway? I think we're all in sort of different places. Most of us are psychiatry residents. So some of us are in the inpatient units. And some of us are doing hospital, like medicine hospital floors and dealing with that. So we're kind of all over the place. Okay. But more like all sort of inpatient right now. Okay. So you're all working inpatient, but kind of into the different areas. Okay. All right. Are you enjoying it? I see blank stares. Are tougher than others in terms of schedule, but everything's okay. So schedules. Yeah. Awesome. Well, I appreciate you guys. Oh, no, I can't. I saw you. I saw you on muting. So I was just gonna say it pays the bills. We'll come back to that one. All right. Again, I appreciate you all sharing. And I do, like we said, in the next session, we're gonna dig a little bit deeper, we're gonna learn a little bit more about culture humility. I believe the worksheets we'll be using were sent ahead of time. And so if you have them, feel free to print them out. Or if not, don't worry, we can, you know, you can draw them as you go. And again, will you be using Menti? So we'll prompt you with questions there. But we'll share here. And I think I'm sure you all could use a break. So we can end a few minutes earlier. Unless Courtney, do you have any anything we need to share with the group? No, I don't have anything. You guys have the links for the one o'clock training, correct? That's it. Otherwise, we'll see you guys at one I recorded this. So if there's anything you guys want to go back to, we have that available as well. Okay. All right. Awesome. Well, I'll see you all at one. Enjoy your break. And see you in a bit.

social determinants of health

substance use disorders

racist war on drugs

barriers to treatment

language barriers

health literacy

community resources

cultural humility

self-reflection

person-centered care

psychiatry residents

health equity

clinical practice